E]|[ijiJfugf ririJ|rin]fiirnfrinlfFu^ m u m i i THE LIBRARIES 1 i COLUMBIA UNIVERSITY [H 1 1 ■*- 1 i i 1 1 1 1 i^ fuiJfruil|liiilfruilf?uilFiin]|l^ i i Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/generalparesisprOOchas fi« EOOSTOH MSREITT; M. D. GENERAL PARESIS CHASE GENERAL PARESIS. GENERAL PARESIS PRACTICAL AND CLINICAL ROBERT ROWLAND CHASE, A.M., M.D. PHYSICIAN-IiSr-CHIEF, FRIENDS ASYLUM FOR THE INSANE; LATE RESIDENT PHYSI- CIAN, State Hospital, ISTorristown, Pa.; Member of the American Medico-Psychological Association ; Fellow of the College of Physicians, Philadelphia. Illustrated PHILADELPHIA P. BLAKISTON'S SON & CO. IOI2 Walnut Street 1902 BARTLETT Copyright, 1902, P. Blakiston's Son & Co. "Of the uncertainties of our present state, the most dreadful and alarming is the uncertain continuance of REASON." — Dr. Johnson's Rasselas. PREFACE. In an experience of more than twenty-five years among cases of nervous and mental diseases the author has had frequent occasion to remark the lack of knowledge, among general practitioners, of the details of paresis. It should be remembered that on this branch oi the profession devolves the care of these cases at the onset, and on these members, as the family physician, must rest the responsible decision of diagnosis and early treatment, which, in so many ways, may mean much or little. In searching for the cause of this limitation of knowledge in this prevalent disease, he was doubly impressed with the meagreness of the available material on the subject. To be sure, the current literature is voluminous, but it is scattered, and not in a form to meet the needs of the busy physician. Hence, the writer has set about to com- pile a study of general paresis addressed to the prac- titioner and the student in medicine with the view of laying before them, as clearly as he may, the special features of this wonderful disease, which claims its victims from every walk and station of life. There has been no pretence on his part to settle scientific questions that are still in dispute by investi- gators; neither has there been an attempt to advance original views and individual opinions beyond giving the practical results of his own experience and re- search. In gleaning from the field of medical writ- ings, purporting thereto, he is indebted to a number of friends, whose assistance is herewith acknowl- edged. The illustrations, for the most part, have been taken from the very ample clinical material at Vlll PREFACE. the State Hospital, Norristown, Pa., and the Insane Department of the Philadelphia Hospital, together comprising an insane population of nearly four thou- sand patients. To his friends, the chief medical offi- cers of these institutions. Dr. D. D. Richardson and Dr. D. E. Hughes, he gladly takes this opportunity ot expressing his obligations for the man}' courtesies re- ceived at their hands. In making abstracts from the various authorities, he trusts that a too liberal version of their writings has not, here and there, crept in — a fault into which one may inadvertently fall; and in quoting from them that due credit has been given. If, then, in the profession at large, the writer be so fortunate as to awaken a further interest in a disease so widespread and significant as general paresis, he will feel that the important object of his work has been attained. R. H. C. Philadelphia, July, 1902. CONTENTS. CHx\PTER I. IXTRODUCTORY, . . . . . • . • ^7 CHAPTER II. Synonyms. Definition. Mode of Commencement. Stages, 22 CHAPTER III. Prodromal Stage, ....... 27 CHAPTER IV. First Stage of the Established Disease, . . -41 CHAPTER V. Second Stage of the Established Disease, . . 55 CHAPTER VI. Third Stage of the Established Disease, . . .64 CHAPTER VII. Varieties of General Paresis. Galloping, Circu- lar, Melancholic, and Spinal Forms, . . -73 CHAPTER VIII. Varieties {continued). Simple Progressive Demen- tia, Juvenile Form, Paresis in Woman, and Senile Form, ........ 94 CHAPTER IX. Particular Symptomatology. Moral Perversion. Sexual Instinct. Hallucinations, . . .110 X CONTENTS. CHAPTER X. Particular Symptomatology (^continued ) , Facial Ex- pression. Speech. Handwriting. Gait. Tre- mor. Reflexes, . . . . . . .116 CHAPTER XI. Particular Symptomatology {^conti?iued). Cerebral Seizures. Eye Symptoms, . . . . .127 CHAPTER XII. Particular Symptomatology {continued). Sleep. Pain. Headache. Sensory Disturbances. Tro- phic Changes. Bones. Hematoma Auris, . . 145 CHAPTER XIII. Particular Symptomatology (continued). Blood. Temperature. Pulse. Bladder. Urine, . . 164 CHAPTER XIV. Differential Diagnosis, . . . . . .172 CHAPTER XV. Etiology, ........ 187 CHAPTER XVI. General Paresis following Ordinary Insanity, Re- missions. Duration. Prognosis. Termination. 224 CHAPTER XVII. Pathology and Pathological Anatomy, . . . 246 CHAPTER XVIII. Treatment, ......... 267 Index, .......... 283 LIST OF ILLUSTRATIONS. Plate. Facing Page. Frontispiece. A Typical Face of General Paresis I. Types of the Prodromal Stage .... 28 II. Types of the First Stage of the Established Dis- ease ........ 42 III. Types of the Second Stage of the Established Dis- ease ........ 5^ IV. Types of the Third Stage of the Established Dis- ease ........ 64 V. Types of the Spinal Forms of General Paresis . 88 VI. Type of the Juvenile Form of the Disease . . 98 VII. Types of General Paresis in Woman . . .106 VIII. Specimens of the Handwriting in General Paresis 119 IX. Normal Gait Compared with the Paretic Gait (modification of Mills after Marie) . . .121 VIII a. Right Iridoplegia (Dilatation of Pupil) in Paresis (Mills) 138 IX b. Spontaneous Fractures and Arthropathic Disinte- grations (Charcot per Church-Peterson) . -158 X. Types of General Paresis in the Negro . .210 XL General Paresis Supervening upon Epilepsy in Woman . , . . . . .218 XII. Vertex of the Brain in Advanced General Paresis (Clouston) ....... 248 XIII. Normal Capillaries of the Coitex and Normal Nerve-cells Compared with those in Advanced General Paresis (Clouston and Ford Robertson) 262 Fig. 1 . Station in Tabetic Form of General Paresis (Church-Peterson) . . . . -9^ 2. Arthropathy of Knee-joint in General Paresis (A. S. Roberts vide Dana) . . . . • 151 3. Hematoma Auris in General Paresis (Williams) . 162 4. Degeneration of Nerve-cells in Cortex with Prolif- eration of the Spider or Scavenger-cells in General Paresis (B. Lewis) .... 254 GENERAL PARESIS. CHAPTER I. INTRODUCTORY. In undertaking the study of this mutable malady, one will promptly find that he has entered upon no easy task, if his object be to gain a comprehensive view of it. Let this, however, be no discouragement to the earnest student, though he discover, as he cer- tainly will, that many of the authorities differ in the interpretation of its important features and that some there are who, as partisans of the dual theory^ of general paresis, deny that it comprises a true entity, distinct in symptoms and course. The student should especially keep in view that in this disease he is dealing with a gradual decay of the higher nervous tissues, a decay which destroys the nerve centers, and spreads progressively both in breadth and depth. The causes may differ greatly; but whether the disease originates from premature disease of the arteries, from over-strain and insufficient nutrition, from imperfect rest and reproduction of nerve tissue, or from the changes of relations between brain and ' M. Delaje, a French writer in the early part of the last century, was the first one to advocate its duality, and since then there have been many adherents to this theory. At the present day this belief is held by a num- ber of prominent authors. Of its advocates, Reginald Farrar, in the Jour- nal of Mental Science, 1895, has made the most vigorous attack in late years upon the specific unity of general paresis. 2 17 15 INTRODUCTORY. vessels resulting from injury or disease, certain facts concerning its development are without contradic- tion: (i) The disease is invariably progressive; (2) its action upon brain or cord is very slight in the early stage and difficult to detect; (3) it rarely affects a large part of the brain or nervous system suddenly; (4) it affects first the highest intellectual and motor arrangements, which is followed necessarily by an impairment of the associated mental phenomena; and (5) in whatever manner the symptoms may differ in the beginning, depending on the regions of the cortex involved, and however much they may vary in mode of onset, progress and duration, towards the end of the disease they are markedly similar (Savage). The date of the discovery of general paresis is not more remote than eighty years ago; and to French pathologists indisputably belongs the credit of having first recognized and described it as a special form of disease. There are, however, passages in the writ- ings of Willis, the anatomist (1670), indicating a knowledge of the association of paralysis and insan- ity; and Haslam^ and Perfect, at the close of the 'J. A., a man, forty-two years of age, was first admitted into tiie house on June 27, 1795. His disease came on suddenly wliile he was working in a garden, on a very hot daj, without any co\ering to liis head. He had some years before travelled with a gentleman over a great part of Europe ; his ideas ran particularly on what he had seen abroad ; sometimes he con- ceived himself the king of Denmark, at other times the king of France. Although naturally dull and wanting common education, he professed himself a master of all the dead and living languages ; but his most inti- mate acquaintance was with the old French ; and he was persuaded he had some faint recollection of coming over to this country with William the Conqueror. His temper was verv irritable, and he was disposed to quarrel with everybody about him. After he had continued ten months in the hospital, he became tranquil, relinquished his absurdities, and was dis- charged well in June, 1796. He went into the country with his wife to settle some domestic affairs, and in about six weeks afterwards relapsed. He was re-admitted into the hospital August 13. He now evidently had a paralvtic affection ; his speech was inarticulate, and his mouth drawn aside. He shortly became stupid, his legs swelled, and afterwards ulcerated; at length his appetite failed him ; he became emaciated, and died December 27 of the same year. (Haslam on Madness, London, 1809.) INTRODUCTORY. 1 9 eighteenth century, reported cases having a combina- tion of the two series of symptoms, of paralysis and de- mentia, but both of them failed to recognize, as did Wil- lis, the clinical import of their observations. In 1815, Esquirol, under the head of monomania in his Mala- dies Mentales, noted the fatal nature of parah^sis with failure of speech, but he also did not have a clear con- ception of general paresis as a distinct type of disease. It is to the pupils of Esquirol that the distinction belongs of actuall}' bringing to light this much-dis- puted disease. Georget (1820) described it under the name of chronic muscular paralysis. Bayle (1822) referred both the muscular and mental symp- toms in these cases to arachnitis or chronic menin- gitis, and later (1825) he observed the changes in speech and the motor disorders. About the same time (1824) Delaye wrote of it under the title of incomplete general paralysis, believing that it was a softening or atrophy of the brain with adhesions of the membranes. In 1826, Calmeil, another pupil of Esquirol, published a complete account of the phys- ical symptoms and anatomical lesions of general paresis, under the title of paralysis observed in the insane. The subject was studied with much zeal by these observers, and especially by Calmeil, to whom is frequently ascribed the merit of having been the discoverer of it. Georget, Delaye and Calmeil re- garded the malady as a special form of paralysis superimposed upon the insanity, that is, as a compli- cation of an already existing disease. Bayle, on the contrary, formulated a new theory, declaring the affection to be a distinct entit}-; he made expansive delusions its necessary characteristic symptom, assign- ing it a regular course and dividing it into three suc- cessive periods — monomania, mania and dementia. Both Bayle and Calmeil were of the same belief 20 INTRODUCTORY. respecting the anatomico-pathological characters, in considering pathognomonic the adhesions existing between the meninges and the convolutions. The views of Bayle gained ground slowly, and in 1838 Parchappe, a prominent observer, reached the conclusion, also, that general paresis was a distinct form of insanity, with characteristic symptoms of motor and mental disorder, which he designated as paralytic insanit3\ Requin (1846) proposed a restric- tion of this view. He contended that the malady, to which he applied the prefix " progressive," may exist without mental symptoms, conceiving the paralysis to constitute the essential part of the disease, although a certain degree of dementia was admitted to be the customary sequel of the paralysis. This theory was further confirmed by other able writers, such as San- dras, Lunier and Baillarger. The latter, who took an important place in the discussions for many years, claimed that the dementia and not the delusion was the chief symptom of the disease, and (1846) he it was who first called it paralytic dementia, a name which has been adopted by many writers even to the present day. From this time forth investigators multipl}', and numerous become the writers on the subject. In 1858 a long and animated discussion took place in the French Medico-Psychological Society, which confirmed the principle of the essentiality of general paralysis. For a long time the clinical analysis of the disorder occupied the attention of the authorities, but of late years the investigations have been directed more to the pathology of the affection. In the latter part of his career, Baillarger returned to " the dualist theory, which he at one time abandoned, that admits the existence of two quite distinct disor- ders, susceptible of existing associated with each other, or separately: (i) Paralytic dementia, the principal INTRODUCTORY. 21 disease ; (2) paralytic insanity, the accessory affec- tion" (Regis). The adherents of this theory are to-day numerous. -"^ Again, some authors, for instance, M. Ball of Paris, look upon general paresis, as a generic term, embrac- ing a variety of diseases, differing in etiology, symp- toms, course and final termination. Hence, we see that there have been in the past sev- eral theories respecting the nature of general paresis, of which the prominent ones may be briefly stated thus : 1. As a complication of insanity: 2. As a distinct form of insanity; 3. If not as a group of cerebral or cerebro-spinal affections, at least as a paralytic dementia, to which is associated more or less frequently, and under various conditions, insanity (Regis)." As an illustration of the former rarity of this dis- ease in this country, it is said that the eminent alienist, the late Dr. Luther Bell, of Massachusetts, at the time of his first visit to England, about fifty years ago, had never recognized a case of general paresis, a statement which seems almost incredible considering its rapid increase and spread in late years, especially during the past quarter of a century. 1" One of the questions which general physicians ask is, whether this same disease, which is called general paralysis, can exist without mental disorder. I always reply that I have seen several cases who for years have exhibited bodily symptoms in every particular coinciding with those found in the patients in our asylums suffering from general paralysis of the insane, and yet without the slightest evidence of insanity, even without any loss of memorj^ or self-control ; so that, in fact, the patient was sound in mind although a general paralytic in body. The reason, 1 believe, that the condition has hitherto been misunderstood is, that asylum physicians rarely see cases in general hospitals ; and general physicians only occa- sionally have the chance of watching true general paralysis. In my opin- ion, general paralysis may develop in any of its forms without mental symptoms for a considerable length of time ; but unless cut short by some intercurrent or accidental cause, mental deterioration shows itself before the end. The symptoms may be only those of weak-mindedness, and may be so slight that comparatively little importance is attached to them." (Savage on Insanity, p. 277.) 2 Mental Diseases, Bannister's translation. CHAPTER 11. GENERAL PARESIS. Synonyms. — General Paresis, Paresis; General Paralysis, General Paralysis of the Insane; Paretic Dementia, Dementia Paralytica (Krafft-Ebing),Para- l\tic Dementia; Progressive Paralysis of the Insane. Other Titles : Progressive General Paralysis; Pro- gressive General Paresis: Paralvtic Insanitv; Progres- sive Paralysis; Diffuse Interstitial Periencephalitis; Paralysie Generale des Alienes; Folic Parah'tique; Periencephalo-^NIeningitis Diffusa Chronica (Cal- meil) ; Paralyse der Irren; Paralytischer Blodsinn; Allgemeine Paralyse der Geisteskranken; Psicopatia Paralitica (Morselli). Definition. — General paresis is a subacute, or chronic, degenerative disease of the brain, often extending to the spinal cord and the large nerve trunks. It is marked chiefly by progressive en- feeblement of the mind and concomitant paresis of the entire body. Mentally, there is moral and intel- lectual perversion, with an abnormal sense of well- being, or actual delusions of exaltation, followed by slow dementia, to which is generally superadded insanity of the maniacal, melancholic, or confusional type ; physically, there is gradual development of tremor, pupillary changes, loss of coordinating power, especially of speech and gait, trophic complications, occasional epileptiform or apoplectiform seizures, and finally paresis. The Mode of Commencement. — The very early indica- tions of general paresis are frequently so ill defined as to STAGES OF GENERAL PARESIS. 23 escape recognition, and their true import, even by a competent observer, cannot always be estimated, the difficulty being less when they are more or less sig- nificant, and the ensemble receives due consideration. There are two accepted forms of onset — the grad- ual and the sudden. In the latter, there is nothing to warn before " the storm has broken." A sudden attack of acute mania may be the precursor; or a variety of cerebral seizure, such as an epileptiform, or apoplectiform attack. Some writers believe that in these attacks and, also, in the cases where a violent shock or an accident appeared to be the beginning, the real beginning was much earlier and 'to be sought in some of the vague warnings enumerated in the prodromes. According to these observers, and with plausibility, the beginning of the disease is seldom sudden in onset. It should be kept in view that the changes at first are inconsequential when taken by themselves, but grow gradually more distinct in the progress of the invasion. The course of the disease depends, also, on its type, whether (<2) depressive, (3) expansive, or (c) demented; many cases are earl}^ tinged with a slightly somber or melancholy aspect, which may pass unnoticed. Stages of General Paresis. — It has been customary for authors to divide this disease into stages, but there is considerable variation in these classifications; some writers make only two or three divisions, others four or five. It may be seen, therefore, from this diversity that these divisions are merely artificial and that the demar- cations are not readily discerned in practice. There is, too, not much utility in this classification, excepting as it may be of aid in the study of its evolution, and for purposes of clinical description. But here even this separation of the disease into stadia may be accounted 24 GENERAL PARESIS. by some as of limited value, because of the wide diversity of its course. In some cases no distinct stage can be traced; in some the ph3-sical symptoms are prominent from the beginning, in others not; sometimes the course is rapid, at other times it is slow; and so too with the epiphenomena, they may be present or absent in varying degree. In these pages, for the reasons above mentioned, the plan has been chosen, of making four typical divisions, which correspond to the following order: 1. A prodromal stage, or period of moral and mental alteration. 2. A stage of decided mental alienation, or of dementia only. 3. A stage of chronic mental disorder. 4. A stage of fatuity (Mickle). Or thus expressed: 1. A prodromal stage. 2. That of fibrillar tremblings and slight incoordi- nation of the muscles of speech and facial expression, and of mental exaltation with excitement. 3. That of muscular incoordination and paresis, with mental enfeeblement. 4. That of advanced paresis, with little power of progression, almost inarticulate speech, and at last paralysis, with mental extinction (Clouston). A HYPOTHETICAL CASE OF GENERAL PARESIS IN THE PRO- DROMAL STAGE. Male, 40 to 45 years old, single, of robust habit and good previous general health, (in some cases a syphilitic history may be obtained) ; no distinct insane ancestry ; of sanguine temperament. Mentally intelligent, more rarely accomplished or highly educated ; active, energetic, specu- lative, sanguine of success ; disposed to be changeable and fickle. Fond of society, a bon-vivant, and self-indulgent in every way with tendency to excesses in drink and sexual STAGES OF GENERAL PARESIS. 25 indulgences. After a sudden reverse in hopes, preceded by a period of mental strain, patient shows change in character and conduct ; rarely, by great depression, usually by an unusual mental excitement, often amounting to a distinct elation. The patient's spirits are high, such as an extra glass of alcoholic stimulant would give. The patient busies himself in various matters, exhibiting a constant garrulity and an entire absence of reticence, with egotistical brag- ging ; he will button-hole persons, almost strangers, and relate to them his confidences. He exhibits very little physical change at this epoch. His elevation may lead him to social indulgences or drink, (thus, alteration in behavior is frequently ascribed to intoxication). Mental character is one of restlessness, followed by mental con- fusion ; patient makes y^//'.v_^(75 of various kinds, such as shown in the following incidents. A gentleman walked into a drawing room without removing his hat and lighted . a cigar. A poor woman openly stole some plants from a window. A woman coming out of a church took a hand- ful of silver from a plate held at the door without any attempt at concealment. A married woman began to un- dress herself by a countr}- roadside. A woman ordered a pair of breeches for her husband, a bricklayer, to be made of moire antique. (Abstract, Sankey, Lectures on ]\Iental Disease, p. 255.) TYPICAL CASE OF GENERAL PARESIS IN A MAN. Clarence E., married, aged 37 ; wine merchant. No in- sane relatives ; not very sober habits. Anxiety the supposed cause for this first attack of insanitv. He had followed many different occupations during his life. He had had a fit before admission. On admission, he had mania with exaltation: imagined he was the eldest son of God; was formerly a great duke ; and had unbounded wealth ; also said that he slept twentv to sixtv hours a night. Occa- sionally he would say that he had lost all his delusions, but it required only a short conversation to get evidence of their persistence. He could not appreciate facts. He lost strength and flesh rapidly during the first few months of 26 GENERAL PARESIS. his admission, and there was an increase of tremulousness in his facial and lingual muscles. He walked about rest- lessly for hours and wrote endless letters to great people. His memory was markedly affected and his sense of color was changed. Six months after admission, for a few days, his speech became affected, and there was loss of power in his extremities, but there were no distinct convulsions. He recovered from this and ate and slept well. He had pneu- monia in about a year after admission. During the next year he was much better, walked in the garden. How- ever, his handwriting was shaky, and early in the next year, two and a half years after admission, his aspect be- came dull and expressionless. He was unsteady in his gait and on several occasions fell, but his muscles were fairly well developed. His memory was failing and he was easily moved to tears. His average temperature was 98.4° in the morning and 100° at night; he had no control over rectum and bladder, and had loss of sensibility. In May of the same year, he had a convulsive fit, from which he recovered, and for a month afterward gained flesh. In the following year, he was fat, flabby and demented, unable to stand ; reflexes very exaggerated ; appetite good ; limbs somewhat contracted ; right pupil large ; he laughed senselessly when spoken to and resisted interfer- ence. He was threatened with bed-sores. In latter part of same year, he had severe convulsion affecting right side ; he recovered, but was in every way weaker, legs becoming contracted and he ground his teeth. During the next year and as long as he lived he never regained con- sciousness ; swallowed food automatically but never artic- ulated. Optic discs were pale and atrophied, but he could hear and see a little. He remained in bed, his limbs drawn up, till August, when he had a fit which was pre- ceded by a condition of extreme reflex irritability ; head was drawn to right side ; right pupil was large ; he had clonic spasms of lower jaw and occipito-frontalis muscle. He recovered from this, but died, worn out, in March of the following year, about five and a half years after admis- sion. (Abstract, Savage on Insanity, p. 299.) CHAPTER III. THE SYMPTOMS OF GENERAL PARESIS. The Prodromal Stage. {First Period.) Mental Symptoms. — There is, perhaps, no disease that begins more gradually than general paresis, for the period of inception, although varying within wide limits, may be prolonged over months, or even years. If one has the opportunity to observe closely the life of the pa- retic and at the same time to gather from his friends all of the data obtainable, it need not cause surprise to find that the first changes in the feelings, the intel- lect and the organic functions of the subject, which mark the appreciable beginning of the disease, extend into the past for many months, and sometimes for a number of years, prior to its apparent onset. At first, the patient is conscious of feeling that he is not in his normal condition, but as the disease advances, he loses the power of discrimination, and he then insists that he is entirely well. Savage refers to a physician who correctly diagnosed his own case as that of paresis, but soon forgot his misfortune in the blighting effects of the advancing disease. In another case, the patient pointed to the top of his head, and said that, like Swift, he was " going first at the top." For the moment he appeared emotional, but in the feeling of bien-etre, which was developing, he forgot his troubles, when induced to speak of his fine capabilities. Lewis tells of a talented mathe- matician, in whom the early symptoms were intense despondency and sudden lapse of attention and mem- ory. Often when solving a problem, he would cover 27 28 SYMPTOMS OF GENERAL PARESIS. his face with his hands, and rising from his chair with a pained expression, hurriedly remark, " It's of no use, it's all gone!" He frequently confessed how painful such a state was to him, realizing most fully the sad condition of his mind, before the final disruption occurred. In former years, alienists were disposed to set the limit of the initial stage at a much shorter length than experience teaches us now to do. Formerly, it was placed at two or three years, or less ; to-day, it is not unusual to see it placed at eight or ten years. There is a preparalytic period, analogous to the pre- taxic period of tabes. Generally, the earliest signs observed are those of mild brain failure, indicated by a somewhat enfeebled state of the mind. This mental failure is shown by a change in the disposition and character of the patient, not at the start ver}- pronounced, but soon issuing in habits and conduct at variance with his normal pro- clivities, which become more and more bizarre with the lapse of time. An intelligent merchant, in good social standing, acquired an ambition to become a pugilist, frequented low places of amusement and taverns and became acquainted with several prize- fighters to whom he paid large sums to be allowed to beat them (Spitzka). The change of character may be detected also in some loss of interest by him in his affairs, or in an impaired ability to attend regularly to them. There is some obtundity of the intellectual and volitional vigor of the mind, and the judgment is more or less clouded. He is varyingly absent-minded, indifferent, apathetic, or negligent in both his domestic and business relations. He seems unable to keep his attention for a length of time to an}' fixed purpose, albeit he can follow out in a fairly correct manner the routine of his daily life, if its duties be not too TUte I. THE PRODROMAL STAGE. Since 1885 it has been the custom]to photograph systematicallj' the patients at the State Hospital, Norristown, Pa. From this large collection of photographs of the insane, these and most of the succeeding t>-pes herein shown, have been selected b\' permission. THE PRODROMAL STAGE. 29 intricate or exacting. It will be seen, also, that he is especially deficient in initiative action, and when he actually takes up a new project his attention soon wanes, and his interest flags. Moderate exercise causes unwonted fatigue of mind and body, which if pressed may end in great confusion of ideas. Fol- som observed a marked change for the worse in the tremor, which appeared in the handwriting of a doubtful case, after the tiresome effort of a long walk; and Lewis describes a case where the man was thrown into convulsions by pressing him into close application, in the solution of a mathematical prob- lem. Transitory states of forgetfulness uniformly occur, to which cause some authorities attribute many of the inconsistencies and absurdities that characterize the disease, particularly at a later period. It is related by medical jurists that a physician prescribed sixteen grains of tartar emetic, instead of one sixteenth of a grain, and a Russian doctor was sent to Siberia for a similar mistake. There is loss of memory, which is shown in many ways, chiefly for recent events and for proper names; it is seen in the misspelling of words when writing, omitting letters, or leaving words out of sentences; it leads to incongruous acts; disregard of personal rights, and neglect of social duties and courtesies. One patient sent home a wagon-load of snow-shovels; another bought a dozen sets of weights and meas ures; another sent out agents into the country and purchased all the turkeys' eggs he could get, and an- other drained the florists of tulip bulbs. A gentle- man, as an early S3'mptom, stole the silver forks and spoons from the tables at which he was invited to dine, and was at length detected with, a silver sugar- bowl in his pocket (Hammond). " We see, in short," 30 SYMPTOMS OF GENERAL PARESIS. says Lewis, " in his whole manner of life a weaken- ing of mind, such as may be noted in the commence- ment of senile dementia, but which occurring in a fine and vigorous man of, it 'may be, thirty-five, too surely indicates the ruin even now commencing." The feelings are intensified and readily stirred, or are excited by trivial causes. There is frequently, even at this early stage, much display of irritability, restlessness, fickleness and temporary loss of self- control under excitement; and, also, a change in the affections, so that persons previously dear to the patient may become hateful to him. From the first, often a sense of well-being is present, which may issue in despondency without adequate cause, but just as frequently in sudden alterations of mood from one extreme to another. Innumerable instances of irritability could be given. A paretic was turned out of the theatre, because he was unable to show his ticket (having in his amnesia either thrown it away or forgotten where he put it) and then broke a large pane of glass to climb in by another way (Spitzka). Another, at a fashionable club, of which he was a member, finding some delay in getting a cigar, impa- tientl}' kicked out the glass of the case and began to help himself. Sometimes the forming period of general paresis is called the medico-legal stage, because of the moral perversion so commonly seen at this time, which may lead the person into difficulties that call for the inter- vention of the law. The disease not being recog- nized, the patient is mistaken for the ordinary offender, and not until he has been arrested, or perchance later, does the true state of the case become revealed. De Boismont gives the case of a man who began thieving eight years before the diagnosis of general paresis was made. A reputable plumber, among the writer's THE PRODROMAL STAGE. 3 1 cases, was arrested for fraudulently tapping a city gas main, without a certificate, nearly a year before other discernible symptoms appeared. In another case, a sedate married man was arrested, three years before he was adjudged insane, for indecent assault on a colored woman, and he was emulged of a large sum of money before released from his unfortunate plight. It is, therefore, not an infrequent experience in asylum life to receive sufferers of this disease who have been subjected to the ordeal of imprisonment for misde- meanor or some grade of crime. When a few or more of these signs have existed for a variable period, the true nature of the malady becomes better defined by symptoms of a more marked character. The sense of bien-etre passes into a gene- ral feeling of elation, an unbounded egotism shown by the exalted opinion that the patient has conceived of his attainments, of his prowess, or of his social and political eminence. The elevated feelings beget a restless spirit, inducing unusual and useless activity. It especially applies to the ordinary affairs of life; there is a scheming disposition, which leads into extrava- gance of all sorts greatly in excess of the patient's resources, and may result in a change of occupation. Generosity and avarice go hand in hand; while just debts are ignored and the family neglected, articles of doubtful utility are bought recklessly, or necessary ones exchanged for those of no value. It will be perceived that these signs indicate only an alteration in the character of the individual, brought about by a mild enfeeblement of the mind, requiring to be looked for sharply, and not a true alienation. This altered condition is compatible, as we have seen, with the performance of customary duties, and con- sequently may readily be overlooked by the casual acquaintance. " The patient," Lewis very justly says. 32 SYMPTOMS OF GENERAL PARESIS. "hovers on the borderland of delusional perversion. The judgment is enfeebled and clouded — not neces- sarily perverted — and the condition is, in fact, one of over-balance." Prodromal Stage. i^First Period?) Physical S3'mp- toms. — The concomitant physical symptoms, becom- ing progressively graver, should be sought primarily in some of the indefinite manifestations, which, taken alone, may be misinterpreted as purely of a functional nature, or lead to error by being mistaken for those of neurasthenia, with or without h3'steria, or uncom- plicated cerebral asthenia. Ballet reports that one of the most brilliant French novelists of recent years was energetically treated, for several months, with douches, as a neurasthenic, before the obvious signs of general paresis were observed. Stearns tells of a paretic, who, unable to attend to business on account of restlessness, was treated by the family physician for malaria. There is an impressionable state of the vaso-motor system, giving rise to palpitation with flashes of heat to the head and alternate pallor and redness of the face. The physiognomy, in some cases, changes; the face, then, becomes fat and loses its expression and no longer reflects accuratel}', as in health, the work- ings of the mind. Fleeting pains of a neuralgic or rheumatic character are felt in different parts of the body, or the pain may be localized; then may follow cardialgia, epigastralgia and rhachialgia. A woman patient had had neuralgic pains six years before men- tal symptoms appeared. Whenever these pains sub- sided, as they frequently did, there occurred numb- ness and, at times, loss of sensation in feet and ankles (Stearns). Insomnia is frequent; sleep being either absent for longer or shorter periods, or disturbed by dreams and nightmares, or is unrefreshing. The pa- THE PRODROMAL STAGE. 33 tient complains of general malaise, and often of dull headache, which is either sincipital, temporo-frontal, or occipital. Some cases speak of girdle pains, as if tight bands were being drawn round the head, or round the body, as in locomotor ataxia. Local anes- thesias or paresthesias with tingling and formication of the skin are not uncommon, as well as various painful sensations, of heat, of cold, and of pressure; loss of sight, optic neuritis; affections of hearing; alterations in the senses of taste and smell; and sometimes sensations of electric currents in the head. Some patients have the feeling that they are walking on air, and experience little or no fatigue after much exercise; others are dull, heavy, and are easily tired without receiving relief from rest in bed. Vertiginous attacks occur, but when mild they are liable to escape attention; also hummings, whistlings, and sounds of bells in the ears; and almost always there is an ab- normal reaction to alcohol and drugs. There may be digestive disorders, such as gastric crises (Hurd), capricious appetite and irregular action of the bowels. The circulation is sluggish and there is often a dull leaden color to the skin, as seen in persons who suffer from hepatic disorders. In the female, dysmenorrhea and amenorrhea are often noticed, the latter more frequently than the former. At this early period, even, there may appear motor troubles which from a diagnostic point are most sig- nificant. Among these may be mentioned a tremor of the muscles about the mouth and naso-labial folds; a fine fibrillary quivering of the tongue, or a coarser twitching of individual fibres; and an incoordinate jerky protrusion of it under voluntary effort. A slight slur or hesitation in the speech may sometimes be detected. Pupillary anomalies (contracted, irreg- 34 SYMPTOMS OF GEXICRAT. I'Al^ESIS. ular, sluggish, or unequal pupils) may also coexist, or may antedate other symptoms for a long time (Griesinger). In one of Campbell Clark's cases the only motor symptoms observed for years were small pupils, tremor of the tongue and of the left depressor ahnc nasi. Not least in value, as forming a highly pertinent group of symptoms, are certain epilepti- form, or apoplectiform seizures, which, occurring at any stage, are grave forebears. In point, Folsom relates these two interesting cases: An express- delivery driver had epileptiform seizures for five 3^ears before he became so forgetful and inattentive that he was discharged. He then had other svmp- toms of general paresis; a prodromal period of five years resulted in this case. A Boston ladv was treated in the Isle of Wight, for four years with bromides for epilepsy. After her return home, she was supposed to have nervous prostration and convulsive attacks ot hysterical origin. A diagnosis of general paresis was made by Folsom, and her subsequent career proved it to be correct. Some of the authorities, from two of whom these selections have been made, tersely summarize the prodromal symptoms : Take note of earl}^ fatigue, fainting or other fits, loss of smell, vague optic disc changes, unaccountable knee phenomena, unusual headaches, neuralgia and sciatica, changes of char- acter, progressive loss of the highest control, moral lapses and instability in various forms (Savage). When a man in early middle life comes before us who has shown a recent alteration in his whole char- acter, restlessness, irritability, together with utter indifference to the needs of others, and pronounced egoism; and when on examination we can demon- strate the presence of pupillary anomalies and abnor- malities in the deep reflexes, we are fairly safe in THE PRODROMAL STAGE. 35 concluding that we have to deal with a paretic (Berkley). A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE. A patient, ast. 46, had been in an asylum a week, hav- ing been brought over from Ireland. No stutter in speech, no irregularity of pupil, no contraction or dilatation. He had full power and perfect coordination of both hands and feet. He could play billiards and the piano well ; walked with a long swinging stride, which was possibly habitual. Speaking generally, the bodily signs of general paralysis were absent. Mental symptoms afforded more information, although these were not very marked. He had no very ex- travagant delusions, thought himself wonderfully lucky, as he had bought five or six horses for small sums from which he was to realize some hundreds. He was gay and jocose, on the best of terms with his friends ; he showed loss of memory, for he said that he had left Ireland three weeks be- fore, whereas it was only one. Although told that another physician and myself were doctors come to examine him, he never tried to persuade us to let him go, though he said he was quite w^ell and needed no doctors. He was pronounced paralytic : (i) On account of the peculiar " larkiness " and hilarity exhibited to two perfect strangers who had come to examine him ; (2) his self-satisfaction and ideas of gen- eral good luck and success ; (3) his indifference with regard to being released ; (4) his loss of memory. (Abstract, Blanford, Insanity and its Treatment, p. 302.) A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE. A man forty-five years old, vigorous, married, of a healthy family ; never had serious illness ; denied history of syphilis. An extraordinary salesman with a salary of $4,500 per year; he lost his position, because he had lost his faculty of making ready sales. His wife found that he had not saved any money, that he could not tell what had become of it, and that he could not be depended upon to earn anything. He became indifferent rather than idle ; placid, apathetic, absent-minded, unenergetic ; therefore 36 SYMPTOMS OF GENERAL PARESIS. he could not get a position. He performed the ordinary duties of the house. Subsequently, he went to the door inadequately dressed, and in other respects he showed a lack of a sense of delicacy, but he did not realize it. He became inconsiderate of his wife, and he showed de- creased sexual power, and increased desire. Upon ex- amination, it was found that he could converse intel- ligently ; he had lost some flesh and strength, but had good appetite. Unnaturally deliberate in conversation,- somewhat sluggish in speech ; a lack of animation ; a failure in quickness of memory and intellectual prompt- ness such as no one worth $4,500 a year would have. On this account, he went to an asylum, where marked intellectual impairment soon appeared. He died a pa- retic. (Abstract, Folsom, Rept. Trans. Assoc. Amer. Phys., p. 6.) A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE. A strong, healthy man in prime of life, had overworked himself to get education ; became successful lawyer ; mar- ried, three children and lived well. He was made mayor of his city, and chairman of local Republican committee ; a witty and fluent speaker, in better spirits than usual. It was afterward noticed that he lacked his usual good sense and judgment. He grew careless in business, and slighted his friends, so that he became very unpopular. On one oc- casion, promising to speak at a Republican party meeting, he w^ent to another city and spoke before the opposition, ably denouncing his own party, but never giving an ex- planation for disappointing the audience before which he had promised to speak. His business letters needed to be revised before leaving the office. His mistakes were sup- posed to be due to his many outside interests. He was coun- sel in a contested will case, involving millions, two years after the beginning of the symptoms just related. Phys- ical weakness was the only S3'mptom to suggest possible illness to his family ; he had fallen once or twice in the street ; and had once been faint and prostrated for several minutes. Finally, a consultation was held, his house THE PRODROMAL STAGE. 37 was turned into a hospital, and he died a typical case of general paresis. (Abstract, Folsom, ibid., p. 7.) A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE. An English actor, robust frame and healthy. His wife observed that he could not commit or play new parts ; lost animation and force in his accustomed parts ; with no con- spicuous faults lost his position. Irritable, indifferent, apa- thetic; slow in mental and physical action; deliberate, tardy speech ; facial expression lost in interest and force ; he had beginning atrophy of both optic discs. One year afterward, he began to show ataxia and personal exalta- tion ; and he was finally sent to an asylum, where he soon died. (Abstract, Folsom, ibid., p. 12.) A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE. C. D., male; set. 38; family history negative; duration of disease two or three years. Friends have noticed for some time that he has been erratic and subject to loss of control ; he was easily excited to anger or violence ; he is rather forgetful ; he has lost interest in his personal affairs ; no mental symptoms present. He shows the fatuous ex- pression common to the disease, tremor of tongue and face (slightly) ; speech clumsy. He has had two or three attacks of aphasia lasting for several hours to a day ; his physical condition is good and at times there seems to be great im- provement in all the symptoms. (Abstract, Fisher, E. D., Journal of Nervous and Mental Diseases, Vol, 18, p. 825.) A CASE OF GENERAL PARESIS SHOWING MOTOR SYMPTOMS FOR A LONG TIME WITHOUT MENTAL IMPAIRMENT. Married man, «t. 38 (no insanity in his famil}^), active and industrious. Noticed a change in his handwriting and hesitation in his speech. Pupils were unequal, tongue tremulous, handwriting shaky, with a tendency to drop terminal letters of words. Increased patella reflex, but no change in his mental capacity. Memory good ; he was not emotional, and he had not lost any power of self-control. 38 SYMPTOMS OF GENERAL PARESIS. He has been under observation for years and has shown no intellectual disturbance ; he is now earning his living (Savage). SYMPTOMS OF DEPRESSION IN THE PRODROMAL STAGE FOLLOWED BY REMISSION OF SOME MONTHS. In one case, the symptoms, which were of weakness and depression, but unmistakably those of general paralysis, passed off, and allowed the clergyman to perform his duties perfectly for some months before he again broke down. (Abstract, Savage, Trans. Ninth Inter. Med. Cong., Vol. 5, p. 400.) A CASE IN WHICH THE DISEASE WAS NOT AT FIRST SUSPECTED. GRANDIOSE DELUSIONS FOR FIVE YEARS WITHOUT MARKED MOTOR SYMPTOMS. R. S., aet. 36, had been in America for some years. On admission he thought he was a general and that he owned property in the neighborhood, and shares in several companies. The only motor symptoms observed for years were small pupils, tremor of the tongue, and of the left depressor alas nasi. There were cicatrices, skin eruptions and other conditions suggestive of syphilis but not very con- clusive. He suffered from strange sensations, particularly, he averred, at the sight of these cicatrices, a feeling as if a battery were connected with these spots. He w^anted mustard for his mouth " to heat the nerve." Developed delusions of persecution ; he became more and more shaky and tremulous ; he had an attack of right hemiplegia, after which his speech became more affected, and from that time onward the downward general paralytic course was rapid. He died after being nine years insane. (Abstract, Camp- bell Clark, Mental Disease, p. 223.) IRRITABILITY AND INDIFFERENCE TO PERSONAL INTEREST OCCURRING AS PRODROMAL SYMPTOMS. A patient had a physical encounter wnth an expressman for leaving one of his trunks on the street instead of imme- THE PRODROMAL STAGE. 39 diately carrying it in. On finding himself in the asylum, he walked up to the scales to be weighed with an air of bravado, and said he was glad of a chance to be weighed " gratis." (Abstract, Spitzka on Insanity, p. 189.) IRRITABILITY AND INDIFFERENCE TO PERSONAL INTEREST AS EARLY SYMPTOMS. A patient, who threw his knife at the servant because she removed his plate before he had, as he alleged, fin- ished dining, heard umoved, a few hours later, of a loss of $100,000 to himself. (Abstract, Spitzka, of. cit.,'^. 189.) INSTANCE OF IRRITABILITY IN A PARETIC AN EARLY SYMPTOM. A man threw a large bottle of ink at his brother and business partner on the latter's asking him the meaning of a certain entry in the ledger. (Abstract, Spitzka, op. cit., p. 168.) PRODROMAL SYMPTOMS APPEARING TEN YEARS BEFORE THE DISEASE HAD BECOME ESTABLISHED. The wife of a patient said that for ten years he had had extravagant ideas as to his powers of money-making and had been more or less erratic, and irritable and occasion- ally he gave way to violent temper. (Abstract, Sinkler, American Journal of Insanity, Vol. 45, p. 79.) A CASE OF GENERAL PARESIS WHERE AT OUTSET THE MOTOR SYMPTOMS WERE THE MORE PROMINENT. M. E., ast. 41. All that could be found wrong in him mentally a year ago was in his manner and carriage rather than in anything he said. He looked a man who thought well of himself, but the weakness of memory, want of method, confusion of ideas and delusions of exalted char- acter were not at first noticeable. The nervous phenomena gave a clue to the nature of the case. The pupils were equal, contracted regularly, the consensual light reflex slight and slow ; the direct light reflex was good. No color- blindness ; reflex dilatation impaired, but fairly marked on 40 SYMPTOMS OF GENERAL PARESIS. shouting or electrical stimulation. Smell good, hearing fairly good. Dynamometer R. lOO, L. 90. Knee reflexes increased ; superficial reflexes and ankle clonus absent. Tongue and speech tremulous, and the facial muscles showed fine tremors when he was the least excited. A few months after admission he had a faint and momentary sei- zure, probably epileptiform, and since then he has degener- ated mentally. (x\bstract, Campbell Clark, oj!*. cit.^ p. 222.) A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE SHOWING MORAL PERVERSION. A gentleman in prison for bigamy ; healthy, 40 yrs. old, married, good character. lie was sent to asylum tw^o years before, because he had married a young girl during ab- sence from home. He was slightly exhilarated when he entered asylum ; talkative, untidy, no motor symptoms. Subsequently his natural manner returned, and he was considered well ; he was removed from asylum and sent to prison. Here it was found that he was inefficient and that he could not concentrate his attention continuously in one direction, although willing to do what he was ordered to do. In time he could not carry potatoes from store- room to cook ; he became very indifferent. Mental and physical strength gradually failed and after two years it was found that he did not do the work because he could not. Folsom found him to be a general paretic. He was sent to asylum with no muscular tremor, or embarrassed speech, no staggering gait or exaltation. Diagnosis was disputed, but typical symptoms finally appeared. (Ab- stract, Folsom, Rept. Trans. Assoc. Amer. Phys., p. 5.) GENERAL PARESIS IN THE PRODROMAL STAGE WITH MORAL PERVERSION. One patient, an eminent lawyer, who had at one time been on the bench, was detected in stealing engravings from a picture dealer. He walked out of the shop with the prints rolled up under his arm, and had reached the street before it was discovered that he had stolen the pic- tures. (Abstract, Hammond on Insanity, p. 598.) CHAPTER IV. SYMPTOMS OF GENERAL PARESIS {continued^. After an indefinite prodromal period, the disease, passing into the next stage either by slow gradations or very abruptly, becomes fully established. This is called the first stage of the confirmed affection, which is now easily recognizable, as a rule, b}' the develop- ment of characteristic mental^and physical symptoms. First Stage of the Established Disease. {^Second Period?) The Mental Symptoms. — The mental symptoms of this stage are indicated by a more pro- nounced expression of those described as belonging to the initial stage. The patient passes from a condi- tion of alteration, as before described, into that of alienation. There is a delusional state of the mind in typical cases, which is characterized by the under- lying condition of mental enfeeblement. If the transi- tion be not gradual, or precipitated by a " congestive seizure," there is then usually an abrupt issue into a maniacal state, accompanied with much confusion and vivid hallucinations. Throughout this stage, when the case is not marked by high excitement, there is commonly a delusional state of mind, and an easy-going self-satisfied air, in the manner of the patient, that emphasizes the pecu- liarities of his conduct. The prevailing type of delusion is that of grand- eur, which is so prominent and constant an attendant that, since the time of Bayle, it has been regarded as one of the distinguishing features of general paresis. These delusions apply to extravagant notions, relat- 4 41 42 SYMPTOMS OF GENERAL PARESIS. ing to self-importance, strength, or wealth. They do not, at this time, always exceed the limits of possi- bility, but when within reason the}' are tinged with the bright hues of exaltation. Vain and confident, the patient is boastfully talkative of the objects of his interest; perhaps he may recount in exaggerated statements his past achievements, which may be partially based on facts; or he builds castles of his future projects. The sense of well-being and the spirit of restless- ness that it engenders, are more pronounced than in the initial stage and pertain chiefly to those interests in his life toward which the patient's attention may be most strongly drawn. Generall}', and in varying degree, it is shown in an exaggerated estimate of his own strength, of his worldly possessions, and of his social and political status. He renders himself an object of curiosity, and too often of mirth, by his boastful talk of his extravagant inventions, plans or investments; by too great laudation of his wife and family, or of some other near object of his affection; and by an exalted view of his own attainments, or of his wonderful intellectual and ph3'sical powers. Con- jointly with sensuality there is an intense vein of re- ligiosity; his S3'mpathies are keenly excited for the welfare of his fellow-beings and he is led into phil- anthropic enterprises, which have for their end the regeneration of the world. He uniformly expresses himself as being in the best of spirits and health; and at no time in his life were his aflairs and surroundings so much to his taste, nor does he remember ever to have felt so well. In his emotional state of gaiety and recklessness, his symptoms are much the same as those of mild simple mania, but the enfeebled character of the mind changes the general aspect of the case. He Hate U, FIRST STAGE OF GENERAL PARESIS. FIRST STAGE. 43 ma}^ be irritable and at times roused to violence, but he can easily be turned from his purpose and calmed into good-natured compliance. To illustrate : Patient, age 60, was admitted as a criminal. He passed a profligate woman in the public park and, with a weapon in his hand, killed her on a sudden impulse. When questioned about it, some weeks after, he re- plied with a smile of self-complacency, "Yes, I killed 300 of them" (Campbell Clark). There is now a persistent tendency to appropriate articles that he can purloin, an increased tendency of the moral perversion that is early seen in the pro- dromal stage. For the same reason, i. e., mental enfeeblement, "the patient bears no malice, is not revengeful, is usually generous, facile and easily imposed upon." Maniacal excitement, as we have seen, is some- times the form of onset of this stage. The .excite- ment may reach the degree of acute delirium, but- this form is not met so often at the present day as it was customary to see it twenty-five years ago. After a variable time the acute symptoms may sub- side, leaving the patient in a comparatively rational state. In due course of the disease there is a return of the delirium, followed again by a partial subsi- dence oi the acute explosion. There may be several exacerbations of this character during this stage, leav- ing the mind each time more clouded. The insanity of this stage more rarely may take the form of melancholia with hallucinations, result- ing in refusal of food, and with delusions of persecu- tion; or the type may be a stuporous form. There is a type, termed the hypochondriacal, in which the delusions, instead of being grandiose, are marked by the opposite extreme. This condition has been called micromania, in contradistinction to megalomania, a 44 SYMPTOMS OF GENERAL PARESIS. state of delusive grandeur. The delusions of the for- mer class are as absurd, extravagant, unstable and unsystematized as those of expansion. The patient who was the emperor of the world one day is the poorest beggar the next; the creator of the universe yesterday is thrown into the deepest pit of perdition to-day; and another who had the best brains, a stom- ach that could accommodate tons of the rarest deli- cacies, and boasted of having a most powerful body, wakes up in the morning to the discovery that his brains are running out, and that his stomach is gnawed away by wild beasts (Spitzka). Medico-legall}', the question of testamentary ca- pacity is one that is often involved when a paretic attempts to make a valid will. Where manifest injus- tice, under the will, has been done, there should not be much difficulty in upsetting it. It is not uncom- mon, owing to perversion and mental enfeeblement, that a "disposing mind" is absent, as manifested by an incapacity of the testator "to understand substan- tially the state of his family and of his affairs; the dis- position of his property as made by the will; and to intend to make such disposition." There is, further, a strong tendency in the pliant attitude of the paretic to a weak 3-ielding to undue influence. One could seldom lind, even in the contiding docility of senile dementia, a more subservient trust than these cases often exhibit toward the influences that surround them. First Stage. {^Second Period.^ Physical Symp- toms. — The general health of the patient is usually very good. As one mildly exhilarated with liquor, he feels well and vigorous, because his subjective feelings are blunted. In this cheerful frame of mind, free from care and anxiety, all of his bodil}' functions are performed normally; he is in the enjoyment of a FIRST STAGE. 45 good appetite and of restful sleep at night. But in consequence of a restless spirit which induces to great activity during his waking hours, the patient is liable to lose flesh, and to appear worn and fatigued. Some of the vaso-motor disorders and sensory symptoms, observed in the initial period, may occur, from time to time, in certain cases, also, in this stage. The diagnostic physical symptoms are to be sought chiefly in the defects of speech, pupillary anomalies and tremor. In the beginning of this stage there is little in the speech that is noticeable to the untrained eye or ear. The defect consists in the slow, slightly labored enun- ciation, as though the patient were speaking with pre- cision; or sometimes there is a lack of promptness in speech, or an occasional eflbrt to enunciate a word. This is followed in time by a blurring of consonants, and a slight thickening of the speech. The patient is able to control individual movements of the parts of the organs of speech, but he is not able to coordi- nate them sufficiently to produce the usual pronun- ciation. There is added to this a certain incoherence of ideas, due to the failure of the power of attention. At first the hesitancy of speech is but occasional. There may be only a slight impediment, perhaps, when the patient is tired, regaining control quickly; or by excitement the disorder may be exaggerated for the time, but he soon recovers his normal enun- ciation. But usually in the latter part of this stage the difficulty of speech becomes more noticeable and fair control of the muscles involved cannot be relied upon. The pupils are often unequal, or the inequality'may not be constant but only occur at times. In other cases they are found contracted; often more or less sluggish to light. They may be irregular_in_shape, 46 SYMPTOMS OF GENERAL PARESIS. one or both; and this feature maybe habitual, or only occasionally present. Dilatation of the pupils is not so common, which is also marked b}^ irregularity. The facial expression in many cases undergoes a change. The eyebrows are raised and when the patient is about to speak the occipito-frontalis is brought together with a tremor. The features are generally florid, and the lines which give character to the face disappear. In some cases a dull leaden complexion is seen, in others it is coarse and greasy. Sometimes in the prodromal period before the mental signs become defined there is an impairment in the coordination of the gait, but this is rare. In this stage, as a rule, the gait is fairly elastic and firm, although there is some ataxy, which ma}' be detected in the uncertaint}' in turning round quickly and even with slight swa3'ing. Going up and down stairs is sometimes accomplished with difficulty and tripping over uneven surfaces is often noticed. Tremor is another prominent symptom in this stage, which is seen at first in the muscles involved in speech, as those of the face, lips and tongue, gradually extend- ing to those of the hands and limbs. Occupations which require delicate adjustment and control of the fingers are early affected, although the handwriting remains comparatively steady and natural throughout this stage. A CASE OF GENERAL PARESIS IN THE FIRST STAGE. F, Y., strong, 35 yrs. old, without any known hereditary predisposition to insanity ; previously enjoyed good health. His temperament is sanguine, diathesis neuro-arthritic, and his disposition frank, unsuspicious, boastful and hasty. He had always a good opinion of himself; imaginative; had a physiological tendency to exaggeration. His feel- ing of bien-etre was above the average ; he was industrious FIRST STAGE. 47 and at times worked very hard. He had lived well, tak- ing not a little of alcoholic stimulants habitually ; eating much, sleeping little ; exceeding greatly in regard to sexual intercourse. He had not had syphilis, and showed no signs of it. In recent months ' ' has not been the same " ; he had flying pains in the head ; was a little forgetful ; want- ing in application to his work, and was irritable at home. A month ago he began to express an exaggerated sense of well-being, so that a stranger remarked: " What a con- ceited fool that man is I " He could not settle down to his daily work. This state went on for some time without awakening suspicion of insanity until one morning he an- nounced that he had purchased several hundred pounds' worth of silver plate, and that he had lots of money, having a scheme through which, in a week, he could be worth hundreds of thousands of pounds. His wife found that he had been buying many useless things, besides the plate ; he had four gold pencil cases, as presents for people whom he did not know. He was sent off to the country ; rest- lessness increased ; constant talking ; almost complete sleep- lessness ; his boastfulness became, in three or four days, exaggerated delusions. He said that he could lift i,ooo pounds, that he was the best rider, swimmer and jumper in the world ; he wanted to buy every farmer's horse that he met, never offering less than lOO pounds and would bid another lOO, if his first offer was refused. He wrote to the Queen and other notables, offering his services to make their fortunes, and asking them to dinner. In writing, he omitted many single words. A few days later, he was so impatient of contradiction that he struck his wife, but he was usually easily managed. He was sent to an asylum, offering to buy it for£ioo,ooo and later, for£i, 000,000. On hearing that they could not get along without it, he said he would build another, the most magnificent in the world, endow it with a million a year, make me physician-in-chief, and get the Queen to make me a baronet, and give me a uniform made of gold cloth. He has been sleepless, destructive of clothing, unclean, in constant motion, facile in some respects, but violent when his commands were not instantly 48 SYMPTOMS OF GENERAL PARESIS. obeyed. He was not surprised at being brought to the asylum, and felt no resentment towards those who brought him. He walks with a quick step, talks rather fast, and has the least slurring towards the ends of long sentences and in articulating long words with many oft-repeated con- sonants. There is fibrillar twitching in the small muscles of the lips, and around the eyes, especially when he breaks into a smile. His tongue quivers in lines on its surface, single strands of muscles being affected. His pupils are contracted, irregular in outline, right larger than the left, which is insensitive to light. Sometimes the right is small and insensitive to light, or large and insensitive to light. The expression of the eyes is feverish and strange ; skin moist; temperature 99.6*^, rising to over 100° at night ; pulse full and hard. He cannot sit still ; has an abnormal gene- ration of energy ; common sensation markedly diminished ; sense of smell somewhat weakened ; tastes imperfectly ; he calls blue wool red. His patellar, spinal and skin reflexes are very acute. He is very easily led from one subject to another; he is very irritable on contradiction. A general paretic will not yield to a show of force. He could walk along a narrow board on the floor all right, but when sud- denlv told to turn around, he could not do so sharply, but took a circle and that waveringly. (Abstract, Clouston, Mental Disease, p. 379.) A CASE OF GENERAL PARESIS OF THE MANIACAL FORM, A REMISSION FOLLOWING TREATMENT. B., male, married, ast. 35, admitted after an illness stated to be of only fourteen days' duration. Previous history : Entered army thirteen years ago. Before this he had contracted syphilis and was supposedly cured. He had several attacks of fever, and later unmistakable signs of secondary syphilis ; but recovered, married, be- came an accountant and cashier, he being without the neces- sary education for the position, consequently broke down, due to the mental strain, while his figures were found to be in confusion. On admission, he was maniacal, impulsive, violent and very strong ; he was very loquacious, incoherent FIRST STAGE. 49 and exalted; he said he was second son of God, very wealthy, etc. ; he offered gifts of £20,000, etc. He suffered much from insomnia, pupils normal, no tremor of lips or face ; no elevation of temperature, organs healthy. The first development of the disease occurred at a dinner at his house, where he had been unusually voluble, and when his wife remonstrated with him, he burst into tears. Two weeks after admission he began to wet his bed, his mania frequently flared out, notwithstanding doses of bromide, throwing knives at those near him, even when unprovoked ; exaltation advanced ; recognized and deplored his loss of memory. Under treatment (calabar bean gr. one sixth, iodide of potassium, ammonia-citrate of iron, hydrobromic acid) he improved very much. Ten weeks after com- mencement, the treatment was stopped and he was pre- maturely allowed to visit his friends, but returned in seven days complaining of headache and insomnia. These were relieved by quiet and h3'drobromic acid ; he was sent to sea- side house for six weeks and then discharged six months after the development of the disease. In ten weeks, he wrote a letter free from the various peculiarities of style usual in general paretics, but saying that his legs were very unsteady, so that while he could play tennis, the fact of knocking one foot against the other was sufficient to throw him down. His mental faculties appeared unclouded, though they were not exposed to any strain. He mingled in society and held his own, but before long the disease returned and he died. (Abstract, Fox, B. B., Journal of Mental Sciences, Vol. 73, p. 389.) DELUSIONS OF GRANDEUR. A gentleman said he could easily run six hundred miles in a minute; that he could fly; that by cutting out his entrails, he should make himself so light that he could jump a mile, and by constant springing could mount higher and higher; that he could speak all the languages. He mixed all his food together on a plate, which he called the kosmos that would make him strong, etc. (Abstract, San- key, Lectures on Mental Diseases, p. 262.) 50 SYMPTOMS OF GENERAL PARESIS. DELUSIONS OF GRANDEUR. One patient proposes to buy up all the water-power in the United States, and let it out to applicants at high prices. He made a table showing, in his opinion, where the power is, its capacity, the price for which it can be obtained, and an estimate for which it can be leased. The profits amount to over a hundred millions a month. Another patient was going into the shipbuilding business, intending to build vessels capable of carr3'ing ten thousand cabin-passengers each, and of making the voyage to Europe in twenty-four hours. (Abstract, Hammond on Insanity, p. 6oi.) DELUSIONS OF GRANDEUR. G. H. believed he had interviews with the Almighty and the Holy Ghost, that he had £40,000 in bank, that he was kincT of England and therefore accused every one of not paying him proper respect ; he promised to clothe the other patients in armor of gold and said the buttons in their clothing were made of his gold. (Abstract, Bucknill & Tuke, Manual of Insanity, p. 313.) A W^OMAN WITH DELUSIONS OF GRANDEUR. A woman insisted that she was the wife of the Saviour ; also of a certain duke, that she had other husbands, more than a million; that God gave her many rare jewels; that she had twenty Koh-i-noors. She exhibited also in these notions a great deal of erotic tendency. (Abstract, San- key, op. cit., p. 262.) EXTRACTS FROM THE LETTERS OF A PARETIC, THE EROTIC PASSAGES BEING OMITTED. My own darling and adored wife Mary : My heart calls you to come to it. Your dear angel presence only can satisfy its constant longing. I count the hours in fear to your coming ; a thousand doubts besiege me night and day. For me there is no light nor life, nor cheer, while thou remainest away. Thou art my Peace, my Hope, my FIRST STAGE. 5 1 only Fortune and the shining angel of my soul. Oh come to me, for you, alone, are mine and you only can still my doubts and fears. My blessed and lovely sweetheart wife, Mary. You must come to me or my heart will break with grief. Come and we will celebrate our reunion and my perfect health, my love and affection, free from care for a week. You are my Queen, all I have is yours, my heart and my purse. I have never destroyed a single letter of yours. I have preserved them all because my love for you has been so deep and tender, so strong and lofty, so ardent and so sacred that I would have deemed myself guilty of a sacriligious act to destroy even one of them. I have them all preserved and you and I will read them over together some time. I am sure it will recall happy hours and delightful memories of our lives in the past. Let us keep on being happy together, for I never was, and never can be, happy when I am away from your easeful and nepenthe presence. In your charming society I often think I am the one man who is renowned because I really and truly love and am loved by you. Ever since your dear kind, sweet, speaking eyes spoke love into my heart you have been the bright and shining angel of my dreams, as you have been the sole Queen of my loving heart and of my delightful and happy home. My darling and revered wife, I so long to see you that I do believe I'll go crazy unless you come. I am constantly thinking and thinking of you ; I never cease to think of you and to bless your dear memory. You are the most blessed wife in all the wide, wide world. I will be, oh so happy when I can get my arms around you. I know of no blissful feeling than to be once again in your sweet, beautiful, gentle, tender and blessed presence. I very clearly see that you are the gentlest and sweetest and the most sensible lady in the wide world. I love you and my dear little boy, J. W. W., esquire, with all the love, pas- sion and vehemence of my heart. And I honor, I dearly love and highly respect the dignified, serene, grand, noble, magnificent and queenly lady, my dear and adored and blessed grandma, X. Y. M. I hope and have prayed to 52 SYMPTOMS OF GENERAL PARESIS. Almighty God to allow and save my dear grandma from death and sickness. I realize that my sweet, darling wife, Mary, will very soon come to see me. There is no such other inspiration as is the inspiration of hope. Hope illumines our pathway through the rough places of earth, etc. I hope to be home very soon. I send to my sweet wife, to my dear little J. W. W., esquire, and to my dear and good grandma, X. Y. M., all the great love of my heart and to you my sweet angel wife, Mary, I send ten thousand kisses. Again he says : I am going home to love my heart's only darling, my sweet, lovely angel wife, Mary, and to enjoy the charming and beautiful society and comradeship of the woman I chose for my bride and wife more than twenty years ago. How well I remember the evening, the hallowed and blessed evening, when I asked you with my arms around you to be my wife and how you then raised ^j^our dark, beautiful, speaking eyes timidly up to mine and murmured the blessed "yes" and how then and in a moment our waiting souls met and embraced in one look of recognition and bliss. Oh, that blessed word " yes " you gave me then ; God has written it upon my heart forever. Never, never, will I forsake the dear lips which spoke that word nor fail in all loving doubt and affection to my sweet Mary to the end of my life. Life is like a bright river when it springs from the fresh fountains of the heart. It flows on beautifully, forever and ever widening until it reaches the ocean of eternity and happiness, etc., etc. A LETTER OF A PARETIC IN THE EXALTED STAGE. " Countess of Elgin and Durham " (but really to Queen Victoria). " House, Royal National Lunatic Asylum." My dear wife : — I am up to the mark and hope that your S3"stem is up to the scratch. Has John Brown undergone any form of cremation? I am glad to him adopting my style of shepherd checked trousers. I hope both queens are well, with Princess Louise, Princess Beatrice, that I will give FIRST STAGE. 53 them all that is necessary in this world and the world to come. Compts. to darling "Eugene." Your affct. hus- band. (Abstract, Clouston, of. cit., p. 383.) A PATIENT PRINTED THE PROSPECTUS OF A COMPANY HE WAS ABOUT TO ORGANIZE, TO ACQUIRE FROM THE PRINCIPAL GOVERNMENTS THE EXCLUSIVE RIGHT TO MANUFACTURE INDIA-RUBBER RATTLES. THE FOLLOWING IS THE COPY OF A FEW PARAGRAPHS FROM HIS DOCUMENT. Everybody, from the infant in arms to the decrepit old man, likes to make a noise in the world. The noise that should be made is a gentle, undulating, penetrating, but not irritating jingle. Experiments show that such a noise has the soothing influence of opium and chloral without their danger. I have established the fact, after expend- ing $10,000,000, that the best rattles for the purpose are made by a silver bell enclosed in a hollow india-rubber sphere, to which a handle is affixed. Thus constructed, the rattle in the hands of either infancy or old age, the youth or adult, the maiden or her lover, the old maid or the bachelor, the widow or the widower, the barbarian or the civilized man, the king or the subject, the gentleman or the ruffian, the honest man or the thief, the Christian or the Jew, the saint or the sinner, the gentleman or the blackguard, the moral man or the hardened wretch who panders to the most depraved appetites of the scoundrels, who fatten on the life blood of the people — all, all, must have the india-rubber, health-giving and mind-soothing rattle. The undersigned has devoted over two hundred and fifty years, both in this world and in a former state of existence, to the investigation of the properties of india- rubber and silver. He has ascertained, after many failures, and the expenditure of over $20,000,000, that the}- exercise health and life-giving properties to all men. Rattle and you will live, rattle and you will be happ}', rattle and you 54 SYMPTOMS OF GENERAL PARESIS. will prosper, rattle and you will be successful, rattle and you will be able to procreate more children than the uni- verse can contain. A company must be organized to carry out the bene- ficent objects which the undersigned has in view. No subscriptions in money are required, as he has taken all the stock, to the extent of $1,000,000,000. He is now contracting for all the rubber the world can produce, and is about bu^'ing two hundred of the richest silver mines in the world. Every man, woman and child on the face of the earth will require several rattles, for, by varying the tone of the bell, different properties are given to the rattle, and hence the same rattle will not do for every person or for ever}'^ purpose. Come up, therefore, and aid in this grand undertaking in which profits of thousands of millions of dollars will be made every year, and the human race rendered happy. (Abstract, Hammond, o^. cii., p. 601.) CHAPTER V. SYMPTOMS OF GENERAL PARESIS {continued). Second Stage. {Third Period^ Mental Symptoms. — The failure of mind is most apparent in this stage, and the patient is no longer able to form new ideas, but gives expression to the old delusions, in a de- sultory, stupid manner, characterized by increasing dementia. They are but the automatic semblance of grandiose ideas, conceived when the memory and the imagination had not lost their strength and scope. The conduct of the patient assumes the uncertain and foolish actions of a child; and there is no extrava- gance too bold, nor any absurdity too grotesque, to which his attention may not be invited. He becomes less and less trustworthy and responsible, without limit to the nonsensical lengths to which his caprice may carry him. He loses all appreciation of his sur- roundings, and all sense of the proprieties or of shame. He gathers together in his pockets rubbish of every description, to which he attaches much value, being able no longer to discriminate between what is his own and what is the belongings or the rights of others. While careless and neglectful of others, he fails to discern his own interests, and in the matter of per- sonal appearance he is not only thoughtless, but falls into the slovenly habits that at a later period become faulty and unclean to an extreme degree. At this stage the appetite is apt to be voracious, and in eating he displays the instincts that belong to an animal, rather than to the human kind. Forgetful often of the amount of food partaken, he is ever ready 55 56 SYMPTOMS OF GENERAL PARESIS. to indulge, until he reaches the excesses of the glut- ton. In the latter part of this stage, the rumination spoken of by writers, takes place in long and distress- ing periods of grinding of the teeth. Second Stage. { Third Period.) Physical Symp- toms. — Concurrently with the increased mental im- pairment there is a deepening of the physical symp- toms, denoted by graver nervous disturbances. In the tirst stage the patient usually loses flesh, but in this stage he takes on flesh conspicuously and becomes stout and flabby. A distinctly impaired articulation is now a marked feature. The character of the speech has often been compared to that of a drunken man. The patient seems to stumble over his words, and at the same time his enunciation is halting and blurred. The labials and Unguals prove most troublesome, as may be seen from the attempted pronunciation of such words as "perambulator," "artillery," "immovability," " cavalry brigade," etc., in which the consonants or entire syllables may be omitted, reduplicated, or even misplaced. Alliterative lines are for the most part impossible to paretics, but as they are troublesome to many people in normal condition, they are scarcely a test. At this stage words may be uttered with an evident propelling force, or the speech may be slow and drawling; there is a frequent omission of words, an entanglement of thought, a forgetting of the idea when half expressed. The tongue can only be thrust out in a jerk}- man- ner with great eflbrt, and fibrillar movements on each side of the mesial line may be distinctly seen. The spasmodic twitchings of the muscles about the mouth, and especially those of the upper lip and of the forehead, occurring with the attempted utterance of a sentence or of a diflficult word, give an appear- PUte III. SECOND STAGE OF GENERAL PARESIS. SECOND STAGE. 57 ance to the face at times that is misleading. The patient attempting thus to speak, appears to be break- ing into a violent fit of weeping (Bucknill). Excitement adds to the disorder. Words seem to struggle for expression, ideas become confused and as the affection increases the patient may become unintelligible in his gibberings, or he may express, with evident delight, new ideas, and use newly coined words, expressing all in a spasmodic hurr3^ After such outbursts the speech is more halting than before. The speech is slow and drawling from the cerebral lesions and stammering or tremulous from the bulbar: " cortical and mental failure are now complicated with ataxia and with paretic defects of articulation." The pupils are now generally sluggish in reaction, both to light and accommodation; they are also irreg- ular in shape and unequal in size. Another anomaly, one is often contracted and the other dilated, while the relative size and shape of the pupils will be found very perceptibly to change from time to time. The underlying pathology of this condition has evoked much discussion in the past. A further statement of these particulars is given under the section devoted to eye symptoms. The features have undergone still greater change than, noticed before, having become " fat and flabby," and the skin coarse and unctuous. The expression has become dull and stolid and some refer to the con- tradictory feelings which are falsely portrayed; one portion of the face giving evidence of an emotion which the other does not reveal. The body settles upon itself, as seen in advanced age, with much stoop to the shoulders. The trunk at times is bent to one side, which may be temporary or persistent. 58 SYMPTOMS OF GENERAL PARESIS. Tremuloiisness of the muscles is a prominent symp- tom. Besides the difficulty of speech due to this cause there is first spasmodic twitchings of the lips and face, which extends to other groups of muscles, controlling the movements of the hands and limbs. Combined with incoordination it soon becomes difficult for the patient to direct his hands and lingers in the perform- ance of the simplest movements, as t3'ing shoes or buttoning and unbuttoning clothing. Shortly the larger and coarser groups of muscles become in- volved so that the gait gets to be clumsily performed. At first the patient walks slowly with care, planting the feet wide apart; there is swerving at times and the line of progress may even be zigzag. He takes short steps, a shuffling, uncertain gait, being liable to trip when the surface is uneven, or fall when attempting to hurry or turn. Towards the end of the stage the commoner habits — walking, talking, writing and eat- ing solid food — are accomplished with more and more difficult}' on account of the muscular weakness, tremulousness and incoordination; at last these habits become abolished. It is at this stage that congestive attacks, usually as epileptiform seizures, are common. On account of other diagnostic symptoms, they are not longer of much value as confirmatory of the disease, as they are in the earlier stage, but they are now followed by marked deterioration in both the mental and physical phases of the alTection. In some cases the seizures may take the form of an apoplectic attack, succeeded b}' temporary loss of power in one limb, or of one side. These cerebral seizures, which will be treated more at length under another division, vary much in character and intensity, being at times so slight as to attract but small attention, at other times so severe as to imply the greatest gravity. SECOND STAGE. 59 ILLUSTRATIVE CASES IN THE SECOND STAGE. R. J. B., admitted to Philadelphia Hospital February, 1895, get. 51, salesman. Family history negative as to mental and nervous diseases. Patient had a severe blow on the back of the head in 1876, which left him with a headache for several 3^ears. He had been a hard drinker. In 1887, after a drinking bout, his friends say that he " acted crazy " for a week or ten days. Recently, he has been indifferent to the wants of his family ; developed de- lusions as to wealth, money-getting, etc. ; pawned any- thing he could get at home ; said he stopped runaway horses, etc. ; gave checks ; signed his mother's name to checks on a bank, where some years ago he had an ac- count ; abandoned his religious belief and joined the new order of the "third Christians." On admission, when asked what was his business, he replied : "I have been a manufacturer of the first character of ladies' shoes for twenty-five years. Our firm is a queer combination, me a Friend, two Jews, and a Dutch Roman Catholic, so we never discuss religion. We do a business of $600,000 a year, the profits being 28 to 30 per cent. We make only the best shoes, silk linings, and many have gold or silver buttons." He said he had not accumulated much money because his brothers needed so much of it. " However, I have been left $6,000,000 in the following way : In Janu- ary, 1877, 1 caught the runaway horses of a gentleman and no doubt saved his life. He took my name and address, and four months ago when he died he left me $3,000,000, and there was a codicil which said that if not satisfied I should ask for more, and so I asked for $6,000,000 more. I also own two charitable hospitals, which I have endowed for $1,000,000." The patient says that he was "Governor of the State; in 1873 Mayor; at the present time he is United States Senator and has been recently nominated for Select Council" ; that he has always had "the biggest ma- jority of any one in this city." In another minute he says he is a graduate in medicine at Harvard, in Berlin, in Paris ; that he has practiced medicine for eighteen years ; that he has been an " elegant singer and player." He is sleepy- 6o SYMPTOMS OF GENERAL PARESIS. looking, nervous in action, calm in mind ; hardly recog- nizes his surroundings; calls the hospital the "Hughes Academy." He seemed to believe exactly what he said. February 12, 1895, his delusions of grandeur are grow- ing greater; he sleeps and eats well. February 15, at 5 .45 last evening he was determined to leave the hospital and broke a pane of glass with a chair, and when the attend- ant tried to quiet him he attacked the latter. March 5, transferred to acute ward and placed in bed ; he has been perfectly tractable and in one week was allowed to get up. He now estimates his wealth at $150,000,000, $50,000,000 of which he made " in as many minutes " ; he is not cogni- zant of his surroundings ; shows no discontent. His face is expressionless and pale ; eyes, partial ptosis ; pupils small, unequal, the right larger ; reaction to light imperfect ; ac- commodation normal ; tongue slightly tremulous ; knee-jerk exaggerated ; no ankle clonus ; cremasteric reflex feeble ; viscera normal. (Abstract, Dercum, Nervous Diseases, p. 677.) ILLUSTRATIVE CASE IX THE SECOND STAGE. F. X., now 45, a clerk. He became affected a year ago. He has gone through a first stage of exaltation and excitement, which for the past two months has been gradu- ally passing off. He has lack of facial expression ; face looks fat, heavy and dull ; even when he speaks his fea- tures do not correspond to his emotions. He is flabby, and has made up in fat for the two stones (28 lbs.) that he lost during the early stage of the disease. He has a con- tented, facile hebetude of mind, and expresses few wants. He says that he is quite well, and that he can walk, work, sing or do business as well as he ever did ; none of which is true, for he is very shaky on his legs and cannot walk a mile. His handwriting is tremulous ; he has no initiative mental power ; no spontaneity ; and no power of volition. He does not obtrude his delusions, but still has them. His pupils are widely dilated, the left more so than the right ; pulse is 68 and easily compressible, his tempera- ture 97°, but still a little higher at night. His tendon reflex is dull, also his spinal reflex functions, and SECOND STAGE. 6l power of swallowing, a little impaired. His speech is markedly affected now and the tone of his voice quite changed. He cannot say such test words as "hippopota- mus," " royal artillery," etc. There are still some tremb- lings about his face as he speaks, but they consist in the incoordination of whole groups of facial and articulatory muscles. He is ver\' kleptomaniacal. The dorsum of his tongue presents a general undulatory surface, when put out. He cannot turn round quickly without risk of falling, or stand on one leg. He straddles a little in walking ; he is apt to stumble over small obstacles ; and becomes almost paralyzed after a long walk. His muscular movements have no vigor. His urine often dribbles away. He is occasionally noisy at night in a careless way. (Abstract, Clouston, ]NIental Diseases, qth ed., p. 384.) ILLUSTRATIVE CASE IN THE SECOND STAGE. A gentleman, ast. 36, owner of a large business ; in summer of 1897, family noticed he was "not quite him- self " ; a transient irascibility and tendency to forgetful- ness. In 1898 symptoms increased, and during an illness of his wife, an emotional state was added ; next, incom- plete parah'sis of internal rectus to left eye, for which oculist gave him glasses and said it would be necessary to have it cut if they did no good. The patient became hypochondriacal ; he was sent to consult a medical man of note, who called it " neurasthenia." The patient was treated accordingly but the downward course was more rapid. In spring of 1899, alarming mental symptoms supervened and the case came to me ; diagnosis of demen- tia paralytica, in the beginning of the second stage. A few days later, he became maniacal, attempted to kill several people, and probably w^ould have succeeded, had not all deadly weapons been removed. I elicited a history of syphilitic infection ten 3'ears ago, also of excesses in alcohol. At first examination, pupils rather small, and reacting slowly to light and accommodation ; consensual movements of iris completely lost ; knee- and wrist-jerks absent. There had been rheumatic pains for several years, 62 SYMPTOMS OF GENERAL PARESIS. and skin about plantar surface of feet showed sligbt anes- thesia ; insufficiency of both internal recti which dated from a few months before and a slight lateral nystagmus. Well-marked fatuity was a striking symptom with a tend- ency to alternate silly laughter and depression. Hand- writing showed slight tremor ; pronounced tremulousness about the muscles of the angle of the mouth and slightly marked speech defect. (Abstract, Berkley, Mental Dis- eases, p. 172.) A CASE OF GENERAL PARESIS IN THE SECOND STAGE ATTACKED WITH CONVULSIONS WHICH PROVED FATAL. H. P., in second stage of general paralysis, was mildly excited and subject to extravagant, grandiose delusions, yet able to read, write, or converse in a connected strain of thought, so long as his delusional ideas were not entrenched upon. Suddenly seized with epileptiform con- vulsions, commencing on left side of the body, but usually spreading to the opposite side ; such seizures occurring several times during the day and night, and lasting for several days together. After their cessation, he was left in a condition of profound imbecility, from which he never rallied ; persistent and copious watery alvine evacuations accompanied the attacks. (Abstract, Lewis, Mental Dis- eases, 2d ed., p. 297.) THE FOLLOWING "PROCLAMATION" WAS ISSUED BY A PARETIC, WHICH IS AN EXCELLENT EXAMPLE OF THE EXALTATION OF SELF IN THIS DISEASE. "To all the people and inhabitants of the United States and all the outlying countries, greeting : "I, John Michler, King of the Tuskaroras, and of all the islands of the sea, and of the mountains and valleys and deserts ; Emperor of the Diamond Caverns, and Lord High General of the armies thereof ; First Archduke of the Beautiful Isles of the Emerald sea. Lord High Priest of the Grand Lama, etc., etc., etc., do issue this my proclamation. Stand by and hear, for the Lord High Shepherd speaks. No sheep have I to lead me around, no man have I to till me the ground, but the sweet, little SECOND STAGE. 63 cottage is all my store, and the room that I sleep in has ground for the floor. No chair have I to sit myself down, no meat have I to eat myself down, but the three-legged stool is the chief of my store, and my neat little cottage has ground for the floor. No children have I to play me around, no dog have I to bark me around, but the three- legged stool is the chief of my store, and my neat little cottage has ground for the floor. "Yea, verily, I am the Mighty King, Lord Archduke, Pope and Grand Sanhedrim, John Michler. None can with me compare, none fit to comb my hair, but the three- legged stool is the chief of my store, and my neat little cottage has ground for the floor. John Michler is my name. Selah ! "I am the Great, All-Bending, Rip-Roaring Chief of the Aborigines I Hear me and obey ! My breath over- throws mountains ; my mighty arms crush the everlasting forests into kindling-wood ; I am the owner of the ebony plantations ; I am the owner of all the mahogany groves and of all the satin-wood; I am the owner of all the granite ; I am the owner of all the marble ; I am the owner of all the owners of everything. Hear me and obey ! I, John Michler, stand forth in the presence of the Sun and of all the Lord Suns and Lord Planets of the Universe, and I say. Hear me and obey ! I, John Michler, on this eighteenth day of August, do say. Hear me and obey ! for with me none can equal, no, not one, for the three-legged stool is the chief of my store, and my neat little cottage has ground for the floor. Hear me and obey ! Hear me and obey ! John Michler is my name. "John Michler, First Consul and Dictator of^he World, Emperor, Pope, King, and Lord High Admiral, Grand Liconthropon forever ! " (Abstract, Hammond on In- sanity, p. 603.) CHAPTER VI. THE SYMPTOMS OF GENERAL PARESIS {coflttnued). The demarcation between the second and third stages is not clearly defined and may not always be determined unless looked for closely. This is espe- cially true of cases in which no episodal phenomena mark the transition. Cerebral seizures are not un- common in the latter part of the second stage and when one of these, as an epileptiform fit, occurs, the patient may be thrown abruptly into the third or ter- minal stage. Third Stage. {Fourth Period.) Mental Symptoms. The progressive failure of mental integrity, which we have seen slowly taking place, finally reaches the point of complete dementia or amentia in this terminal stage. The patient in whom speech-power is practically abolished has now reached the point ol fatuity in almost the entire quenching of all of the higher aptitudes of mind. This impairment is seen in all the content of consciousness— thinking, feeling and volition. As one author aptly says : " The patient actually falls into the condition of a lower order of being, more resembling a vegetable with a digestive tube^than an animal" (Macpherson). Third Stage. {Fourth Period.) Physical Symp- toms. — The reduction seen in the mental sphere may also be seen in that of the physical. The prosperous appearance which ample weight gives to the patient in the second stage disappears often in this by evi- dences of great loss of flesh. The exhaustion and emaciationbecome so pronounced in some cases as 64 PUte IV. THIRD STAGE OF GENERAL PARESIS. THIRD STAGE. 65 the end approaches that the patient is reduced almost to a skeleton. The muscular incoordination and paresis advance to the extreme degree. The muscular tremor is shown by the utmost trembling and shakiness. The gait gets more and more unsteady until the patient falls with any attempt at taking a step; standing alone unguarded soon becomes impossible and seated his body falls in upon itself, so there is danger of pitching forward on the floor. The impracticability of getting him out of bed soon leads to his complete decubitus. Con- traction of his legs, in a flexed position, gradually increases, producing in some cases much deformity. A marked change takes place in the speech of the pa- tient, which is reduced to the formation of very simple phrases; many of the troubles already noticed still ex- ist but in a more pronounced form. The voice may be- come rough and hoarse, or it may become weak and monotonous, always the result of relaxing of the vocal cords. Ideas become more fragmentary, word-deaf- ness and word-blindness may follow. Speech becomes more tremulous until the patient speaks very little, or toward the end not at all. In some cases there is an inarticulate shouting, especially at night, while in others there is but an occasional meaningless moan. The deep tendon reflexes are usually permanently abolished and the pupils no longer, as a rule, respond to light and accommodation. The face has now lost its entire expression, and the paucity of mind is re- flected in the vacant look. Trophic changes soon appear in various aggravated forms. The most com- mon and invariable are bed-sores over the sacral region, where not only pressure but irritating dis- charges tend to increase the complication. It is occasionally stated that bed-sores have their origin in poor nursing and that the occurrence may be. ob- 6 66 SYMPTOMS OF GENERAL PARESIS. viated by care and skill. There can be no doubt that much can be done in this way, as a preventive meas- ure, but there are some cases where no precaution can avail, when even the contact of bed-clothing is suffi- cient to produce sores and every pendent point, knee, elbow, heel and back may be the seat of invasion. In some cases the nervous enervation is so great that erythemas, abscesses, perforating ulcers of the foot, the shedding of the nails and teeth and extensive sloughs of different parts of the body may be encountered. In this helpless state the wretched sufferer lies day after day, with nearly every semblance to a rational being extinct, until death puts an end to the scene. ILLUSTRATIVE CASE IN THE THIRD STAGE. J. E. J., xt. 44, now presents the conditions of the final stage, the previous stages having been typical. He can- not walk or stand, but lies in bed in the position in which he may be placed, barely able to turn his body unassisted. He is now unable to articulate more than a word or two at a time. His flesh is fast wasting, swallows with difficulty, and is fed chiefly with liquid food. His dejections pass unconsciously in bed. But the expression of good feeling still lingers on his face and he never complains. When addressed he sometimes tries to reply and even to smile a recognition, but does not succeed and the semi-flaccid muscles of the mouth and face fail in their effort of move- ment. Bed-sores are hard to prevent. He will become even thinner than at present unless the drama ends by a paralysis of the muscles of deglutition. (Abstract, Stearns, Mental Diseases, p. 505.) ILLUSTRATIVE CASE IN THE THIRD STAGE. F. W., aet. 40, has had general paresis for two years and has passed through the first and second stages. He is so paralyzed that he cannot walk, stand steadily, or write ; his mental state is that of a happy lethargy. When asked if he has much money, his facial muscles begin to THIRD STAGE. 67 act in an incoordinated way, his eyelids half shutting, his mouth being drawn in, -the lips moving spasmodically like a patient going into an epileptic fit, the whole effect being that of a contorted imitation of a smile, accompanied by a slow, prolonged and jerky " y-a-a-a," which is all that he can articulate for " yes." But he looks perfectly happy, and asks for, and complains of nothing. He is unable to retain urine and feces by night or day. All his food has to be liquid or minced, for he would bolt it in solid masses and choke ; he is greedy for food when it is put into his mouth, though unable to feed himself. He had a con- gestive attack about the end of the first stage of the dis- ease, accompanied by unconsciousness ; a temperature of 103°, and general convulsions which began and ended on the right side, but affected the whole body in the middle of the attack ; they lasted for about four hours and were succeeded by stupor, which lasted for forty-eight hours. He had retention of urine as he slowlv recovered con- sciousness ; after that, his speech and walking were more paretic, and his mental power more enfeebled. The second attack was of the same character, though less severe and occurred in the second stage. His common sensibility is so impaired that you can stick pins in him wdthout his feeling it much. The reflex action of his cord is over-acute and extends upwards from the section of the cord irritated, for if you tickle the foot, they are both drawn up with a jerk, and the two hands and chest muscles are contracted likewise. The impression travels upwards more readily than downwards. (Abstract, Clous- ton, Mental Diseases, 4th ed., p. 385.) GENERAL PARESIS FOLLOAVIXG A GREAT MENTAL SHOCK. SAPID IMPROVEMENT. REMISSION AND RELAPSE. DEATH IN TWO YEARS FROM COMMENCEMENT OF ATTACK. A solicitor, at. 58, highly esteemed and in large prac- tice, met with severe family affliction and reverses. After- wards was altered in manner, committed many strange acts, indifferent to his troubles, disposed to quarrel, peevish. Undertook several large schemes at variance with his cau- 68 SYMPTOMS OF GENERAL PARESIS. tious temperament. He would tell his confidences to people almost strangers. Conduct at home strange and excited ; would not go to bed, said he was attacked by Fenians (an attempt recently made on the Queen greatly alarmed him). Accused a Mr. F. of being his enemy. Mr. F. was a Fe- nian. He had all his windows and doors barricaded ; had a forced cordial manner, very garrulous. On admission, general appearance good, was said to have been four weeks ill, in elated spirits, talked much of his schemes, would cut a canal from the west of England to the mouth of the Severn, so that ships could go to Gloucester and Cheltenham ; would build towns in the Cotswold Hills and a cathedral. He would try to improve agriculture and thus make a large fortune. Said Mr. F. was a great de- bauchee, his conversation interlarded with much prurient matter ; easily diverted from one topic to another ; open to slight flatter}^ bragged of his own cunning ; was relieved to be admitted and in security against his foes ; fancies he is in a cave in Leckhampton Hills (was admitted after dark) ; decorated himself with a blue scarf but when talked to quietly, was ashamed and removed it. The day after admission, found out where he was and pretended he was much pleased, praised all the appointments, said he would buy the institution, lost his fear of Fenians. Occupied himself in drawing the scheme for the cathedral. Said he should spend several millions, that the Queen would grant him an annuity of £10,000 and each of his daughters £5,000. His fear of enemies returned every evening. A fortnight after admission, sixth week after disease : He is always elated in spirits, jokes with the most insane patients and considers them perfectly rational. One month after admission : Same symptoms continue, grand ideas, etc., lib- idinous conversation, fears increase towards evening. Five weeks after, visited by wife and friends ; at first refused to see them, then received them cordially ; thought his wife had sided with Mr. F., but fears the latter less than formerly; he has a sense of weight in his limbs, eats largely. Eighth week : Spent a day at home ; has lost his fears, converses rationally, expression much improved, says he feels well. THIRD STAGE. 69 Ninth week : Left for six weeks on probation ; relatives consider him well ; has been quiet and rational ; has slight feebleness of intellect, makes puerile remarks, a certain lameness in his conversation, heavy expression of face, is too much elated over his health, bulimia continues, feels no weight in his limbs. Fifteenth week : received me cor- dially, jokes about his former delusions, all he requires, he said, is his former strength. He was discharged "relieved." A note received shortly after from him, thanked me for care and attention, said his legs still felt weak. On his discharge, he remained at home, unable to return to busi- ness, his mind gradually declining, talked in a childish way, fond of prurient anecdotes, gradually neglected his personal appearance ; was found one day sitting down on the curb-stone. Having been discharged in March he was readmitted in the following August and died in December, two years from the commencement of the attack. (Abstract, Sankey, Mental Diseases, p. 315.) PERIPHERAL NEURITIS IN THE COURSE OF GENERAL PARESIS. The patient was an imbecile whose mother was insane. When aged 22, he began to have characteristic symptoms of general paresis. He had delusions of grandeur, stutter- ing speech, twitching of tongue and facial muscles ; and pupils sluggish to light. After he had become confined to bed, there was paralysis of the peronei muscles, which disappeared after several months and was succeeded by spastic rigidity. (Abstract, Pick, Berliner klinische Wo- chenschrift, No. 47, 90.) GENERAL PARESIS DUE TO BUSINESS WORRY, INTER- RUPTED BY A REMISSION AND MARKED IN THE LAST STAGE WITH CONVULSIONS. Henry W., married, set. 37, silver chaser, no insane relatives, the first attack due to business anxieties ; first symptoms appeared two months before admission, when he bought a plot of land without being able to pay for it. He talked about travelling and taking a hundred friends 7© SYMPTOMS OF GENERAL PARESIS. with him ; was going to build a large house ; become an M.P. and was full of extravagance and joyousness. On admission, he was sleeping, eating, digesting well, pupils contracted, with tremor and hesitation of speech, change in handwriting and restlessness. This attack passed away and in two months he was sent to the convalescent home, and was finally discharged, his friends being warned that it was only a remission. In six months he was brought back, having slept well till ten days before admission. He then became extravagant and did not know the value of money. He collected rubbish, thinking it gold, talked with much hesitation of speech, about millions and the hippopotami he was going to stock his farm with. Expression dull ; tremor of lips and tongue ; pupils small and equal ; skin greasy ; speech clipped and hesitating ; memory bad ; restless and mischievous, tearing books and clothes ; no change in his optic discs. He improved in bodily health, fat and healthy looking. In a year's time he had a fit, the temperature not being raised and only slight convulsions, associated with unconsciousness. From time to time he had fits, alwa3^s of the following nature : Without warning, fell forward on the floor, limbs twitching slightly, uncon- scious for from ten minutes to an hour, passing his urine and feces under him. Recovery was like one waking from sleep ; each fit leaving him slightly weaker mentally. In six months more, vision was noticed to be weak, pupils contracted but not circular, right optic disc very white, edges very sharply defined ; left optic disc pale, sharply defined; knee-jerk well marked. He said he was "very well." The fits recurred ; but during the last month of his life he at times could talk accurately about events that happened two years before, in the hospital. In two years after admission he became unable to swallow, lost flesh rapidly and died. (Abstract, Savage on Insanity, p. 323.) GENERAL PARESIS, DURATION ABOUT TWO YEARS. DEATH IN THE THIRD STAGE. A. S., a female, married, aet. 32, admitted in June ; married twelve years ; previously a domestic servant, of THIRD STAGE. 7 1 excellent character ; lived with her grandfather, a man very much respected ; of short stature, of considerable personal attractions ; had several children ; her health fail- ing, she returned to her grandfather, having been infected with syphilis by her husband ; one or two of her children died. On the death of one, the patient's attack commenced, she being found insensible on the twenty-fourth of Decem- ber. In June following she was arrested for pulling up trees in a nursery, threw her arms around two men on the street and kissed them ; her house was the scene of drinking and other immoralities ; her children neglected and dirty ; her sister said the first appearance of the disease was shown by her ordering a large quantity of furniture. On admis- sion very dirty, temperate, well-nourished, dark hair and irides, slight paresis about lips and face. Expression some- what imbecile ; is reported to have been six months ill on admission. Second day after admission, is excited and talkative, says God is very gracious ; has a very nice hus- band, two children, is going to Margate, etc. ; hesitates and drawls in her speech. Tongue protruded by an effort, not tremulous, coated. Says she has £17,000, that her hus- band has 40 and then 70 millions. She is feeble, at times, wet and dirty, disposed to undress, requiring the dress to be fastened mechanically. Sixth month after admission, twelfth of disease, complains of headache ; eyelids swollen, and crying, is destructive and violent, articulation indis- tinct, hand tremulous, says she has "such beautiful senti- ments." Tenth month, has not spoken for several weeks till to-day, imbecile and childish, voice tremulous and stammering, twitching of both lips, pupils nearly equal, peculiar gait, no grand ideas, is stouter, tongue clean, protruded well, is wet and dirt\'. A seton, inserted in the neck, caused no pain. Eleventh month, able to stand but very tottering, expression slightly improved, knew her mother, and glad to see her, speaks seldom, lies quietly in bed, conversed with her mother, right pupil large. Seton discharges well. Twelfth month, slight improve- ment, speaks more cheerfully, she can stand more firmly, walked without assistance to bath, takes food well, is well 72 SYMPTOMS OF GENERAL PARESIS. nourished. Twelve and a half months, answers questions more alertly, says she feels well, can w^alk with the assist- ance of one person, right pupil dilated. Thirteenth month, when in bed began to lie with knees drawn up, cannot stand alone. Fourteenth month, knees constantly drawn up, is weaker and more restless. Fifteenth month, mind childish but not wandering, not excited, knows where she is, articulation hesitating, syllables slurred, tongue pro- truded well, wet and dirty, knees drawn up, says she can- not put the right knee down. Fifteen and a half months, is getting thinner, both knees contracted, visited by her mother, asked for her children, soon after forgot that her mother had been to see her, takes food well and swallows without difficulty, says, " I like food very much." Eight- eenth month, continued confined to bed, gradually getting weaker, appetite still good, called for food at the proper hour, bowels acted regularly, continued to emaciate though she took food ravenously. Both legs contracted, said she was going to die, voice clear and stronger, but tremulous and bleating, sank and died without convulsion or other marked change. (Abstract, Sankey, of. cit., p. 316.) A CASE OF GENERAL PARESIS PROBABLY SYPHILITIC. MENTAL INTEGRITY YERY GOOD. DIED IN CONVULSIONS IN THE THIRD STAGE. D. N., aet. 59. Probably a syphilitic; at any rate, a gonorrheal history. Excited and exalted ; declared this to be heaven, and a few days later said he had been around the world in the last two days. Pupils small, immobile ; tongue protrusion jerky; speech thick and interrupted. He said he had a letter about his wife and that she was dead — a delusion. Pains in right side followed by hemi- plegia. Accessions and recessions of strength from day to day. For a general paralytic, he was very accurate in observing and reporting his symptoms. Hallucinations of siglit and taste. Bed-sores on right buttock, blisters (trophic neurosis) running down right arm and wrist, later on left arm ; then coma, convulsions and death. (Abstract, Campbell Clark, Mental Diseases, p. 222.) CHAPTER VII. VARIETIES OF GENERAL PARESIS. In attempting to classify cases of general paresis, considerable difficulty is experienced at once. There seems to be no very clearly cut divisions at present, based either on therapeutics, pathology or clinical history into which these cases can be separated. The varieties are divided by Spitzka simply into two types; in the first of which the affection is the ordinary type; the second is that in which the mental symptoms appear after serious evidence of a spinal or axial affec- tion of the nervous system, and hence this author terms this form the "ascending affection." Savage divides the cases into acute and chronic and then into those in which the symptoms are pri- marily maniacal with exaltation of ideas; next the melancholic and hypochondriacal cases; and lastly those in which dementia is more or less pronounced from the onset. He states that it will be seen in tracing the history of cases that nearly all end in dementia sooner or later. In another division he con- siders whether the brain or cord symptoms are most marked, or come on earliest. In considering the latter, he divides the cases into those in which the posterior columns of the cord are most affected, and those in which the lateral columns are chiefly involved. Folsom, in Pepper's System of Medicine, states that well-marked general paresis can be divided into four distinct types, as follows: (i) The demented and paralytic; (2) the hypochon- driacal; (3) with melancholia; (4) with exaltation and 73 74 VARIETIES OF GENERAL PARESIS. mania. There are mixed cases in which some or all of these forms occur. Folsom also believes that the period of invasion or prodromal period, be it short or long, has, as a rule (not always), gone by when the disease has arrived at a point in its progress to be definitely placed in any of these four t3'pes. B. Lewis ^ goes into the varieties of general paral3''sis in greater detail and produces a plan of clinical group- ings in which he feels that all forms of general paral- ysis ma}' be included; this scheme is based upon the predominance of the cerebral, bulbar or spinal symp- toms, their earl}- on late onset and the clinical course pursued. Group I. — Paralytic m3'driasis; a partial reflex iridoplegia (light). Increased myotatic irritability. Excessive facial tremor and speech troubles. Great optimism with profound dementia. Group 2. — Mydriasis with associated iridoplegia rapidl}' passing into the c3'cloplegic form — an early S3'mptom. Frequent m3'otatic excess, but no con- tractures. Late speech troubles. Acute excitement with frequent convulsions. Ver3' rapidl}' fatal course (preponderance of S3'philitic histor3"). Group J. — Spastic m3^osis; a complete reflex iri- doplegia. Absent or greatl3' impaired knee-jerk. Failure of equilibration; locomotor atax3% defective sensibilit3'. Ver3" defective articulation. Much opti- mism and excitement. Group 4. — Late e3^e symptoms : paral3'tic m3'dria- sis, a partial reflex iridoplegia (for light only). Ataxic paraplegia confined to lower extremities (arms do not participate). Great facial atax3' with extreme troubles of speech. Epileptiform seizures ushering in pro- nounced mental enfeeblement. ' Mental Diseases, 2d ed., p. 326. VARIETIES. 75 Groiip 5. — No oculo-motor symptoms beyond oc- casional inequality. No contractures, but notable myotatic excess. No disturbance of equilibration, locomotion, or sensation. Speech troubles not pro- nounced. Epileptiform seizures very rare, but from the first progressive deepening -dementia. The French writers, according to Sankey,^ divide the disease into four varieties as follows : 1. A congestive variety. 2. A paralytic variet}'. 3. A melancholic variet}^ 4. An expansive variety. M. Baillarger insisted upon a h3'pochondriacal, a melancholic, a monomaniacal, and a simple form. It is therefore abundantly evident that the cases of gen- eral paresis show certain deviations in the course of the disease, but, nevertheless, Sankey believes that there will be found running through the whole of each case more or less pronounced general symptoms. Every writer upon the disease admits that such variation, also, in the advent of the various phe- nomena, is not uncommon. As regards the order of occurrence of the mental and motor symptoms, for instance, Sankey^ states that there are described three modes of invasion as possible. Firstly, the case may commence by some disorder of the mental faculties — usually by delirium, or maniacal excitement — but in some cases with depres- sion or melancholy, and on the subsidence of these symptoms the peculiar indications of general paresis, particularly those connected with the motor functions, manifest themselves. This is admitted by most authors to be the most frequent order of invasion. Both Parchappe and Calmeil agreed also that the ^Mental Diseases, p. 277. ^ Op. ctt., p. 277. 76 VARIETIES OF GENERAL PARESIS. special paretic symptoms may follow the mental at any length of time, as after many years, though this is exceptional and not the usual course. Secondly, other cases occur, in which the mental symptoms, as mania, melancholia and especially a state of dementia, are manifested simultaneously with the lesion of motility. Thirdly, MINI. Baillarger and Lunier asserted that, as a rule, the lesion of motility precedes the mental phenomena. Voisin, the well-known authority, has given five forms of general paresis : 1. Acute general paresis in which the course is rapid, the stages are confounded, and death occurs early as a rule. It may suddenly attack an apparently healthy person without an}' warning. 2. The common form of general paresis in which the mental state is generally expansive and ambitious. Often accompanied by epileptiform and apoplectiform attacks. 3. The form in which symptomsof dementia predom- inate (paralytic dementia). It is the chronic form par excellence,and is accompanied byfewsomatic troubles. 4. The senile form connected with atheroma of the arteries. In its course it is next in rapidity to form i. It is very rare. 5. The spinal form in which the medullary troubles dominate the scene, and the intellectual are of sec- ondary importance. It is very irregular in its mani- festations. (Shaw, Epitome Mental Diseases, p. 77.) Another division of general paresis is into four forms, three of which depend on the character of the mental symptoms, and the fourth on their absence or significance: (i) the expansive form; (2) the depres- sive or melancholy form; (3) the demented form; (4) the somatic form (Shaw). VARIETIES. 77 Mickle, in his classic work, has laid down five groups into which general paresis can be divided. The first group consists of cases of a common kind, which exhibit exalted delusions, maniacal excitement and hallucinations. The duration of this condition is short; cerebral hyperemia and softening are observed with adhesion and decortication. In the second group there is found a protracted stage of dementia, the quiet self-satisfaction of the early stage being followed by peevishness or apprehension, till the personal habits become foul and brutish. The duration of this condition is length}-, and the brain seen to be atro- phied with considerable increase of intracranial serum. The gyri of the upper surface and frontal region are wasted, adhesion and decortication are moderate, and the white substance is pale. In the third group dementia is early and predominant, and melancholic delusions are common, the latter course of the disease being one of extreme dementia. Hemiplegia is conspicuous and common, epileptiform attacks being ver}^ frequent. The duration of this condition is brief and on autopsy the left hemisphere is found more diseased than the rio^ht and more or less atrophied. In the fourth group the morbid le- sions are much more conspicuous in the right than in the left hemisphere. The outbreak begins with active dehrium and maniacal agitation, the symptoms of dementia and melancholia noticeable in the third group being wanting. The duration is somewhat lengthy. The fifth group is not well defined. There is much local induration of the cortex and the inter- stitial changes tend to sclerosis; the mental symp- toms are various; epileptiform fits, hemiplegia, and spasms are frequent and the duration somewhat long. (Blandford on Insanity, p. 311.) Mickle also recognizes eight mental varieties in the 78 VARIETIES OF GENERAL PARESIS. first stage of general paralysis. These are: (i) Symp- toms of dementia predominant, in which are found every degree of mental failure and deficiency. (2) Expansive delirium is predominant. Here grandiose ideas and a feeling of elation or quiet self-satisfaction are actively shown, (3) Mental excitement is pre- dominant, with probably, though not necessarily, exaltation and grandiose ideas. There may be excite- ment, mental and motor, or merely silent restiveness, or what is described as the galloping form of general paralysis — raving, violent, sleepless, with t3'phoid-like symptoms. (4) H3^pochondriac S3'mptoms are prom- inent. In such cases the essential mental state may be h3pochondria, with delusions as to the viscera, and especiall3' regarding the liver and bowels. Ac- cording to Mickle, this form is next in frequence to the expansive: according to Clark's experience the first class, the early demented, are more prevalent than the h3'pochondriacal. (5) Melancholic symp- toms prominent. (6) Persecutor3' delusions prom- inent. (7) Stuporose form. (8) Circular form. (Abstract, Campbell Clark, Mental Diseases, p. 207.) According to a few writers there is no division as satisfactor3' as that of " Me3^nert's Eight," which is as follows: 1. Simple progressive dementia with the usual motor impairment which accompanies it, but except- ing h3^pochondrical depression, not necessarily ex- hibiting other mental S3'mptoms than dementia. 2. With the expansive delusions and the distinctive motor disturbances which appear simultaneously and are progressive, constituting the " classic " form of general paral3'sis. The mental state is usuall3' of self- satisfaction and exultation,but there ma3'be depression. 3. Of the same t3'pe as the last, but failing its steadil3^ progressive character through arrest of the VARIETIES. 79 active process. The remissions, which seldom last so long as a year, raise hopes of recovery, but still manifest unmistakable impairment of the reasoning faculties. The psychic disturbances are much greater than can be accounted for by the atrophy of the brain alone. 4. Cases in which the characteristic exaltation and grand delusions reach such an astounding height that manifest motor symptoms are looked for with con- fidence from day to da}' and yet may not appear even for a year, any slight incoordination naturally being obscured by the general muscular disturbance. Meanwhile there may be such an improvement that the patient leaves the hospital for awhile, once, rarely twice, on the responsibility of his famil}', but to return with marked motor, as well as mental, signs. 5. A very rare form, with alternate symptoms of exal- tation and depression of the type of circular insanity. 6. With early furious delirium, painful hallucina- tions, confusion and incoherence somewhat resemb- ling acute delirium. 7. Progressive general paralysis, in which the characteristic indications appear secondary to other forms of insanity; for instance, after paranoia or melancholia, first described by Hoestermann. 8. The combined form with sclerosis in the whole cerebro-spinal tract, the symptoms of tabes or spastic paralysis predominating, according as the posterior or lateral columns of the spinal cord are chiefly involved. The ascending type, in which the cord is first affected, is rare. Optic neuritis ending in atrophy and paraly- sis, especially of the ocular muscles, may precede marked mental symptoms. (Folsom per Hughes, Practice of Medicine, p. 472.) It is be3'ond the scope of this work, addressed as it is to the medical student and general practitioner, to do 8o VARIETIES OF GENERAL PARESIS. more with these elaborate classifications than to enumerate them. But there are a few special forms included in these classifications which are usually described by writers that may appropriately find men- tion at this point. The Galloping Form. — As the name suggests, the galloping form acts in such a rapid and violent man- ner that within a few months, or it may be but weeks, all resistance to the disease is overcome, and death follows after this brief time. It usually assumes a grave aspect from the first, and in some cases mani- acal outbreaks occur, from the earliest stage of the disease. Many times early exhaustion supervenes, then partial collapse and lowered temperature are speedily followed by death. These cases are similar to those of acute delirium, and with these are often confused. Berkley speaks of one case in which slight irrita- bility and alteration of disposition was followed within two weeks by excitement, in the highest degree, with delirium and fever, the malady running its course in five weeks. The same author records another case, who recovered from this attack of seeming acute delirium and was still living after four years, but much demented and showed the characteristic pupils and increase of knee-jerk. Zacher reports two cases of acutely progressive paresis, the first, after a melancholic prodromal state, ran its course in less than four weeks; the second, lasted for two and a half months. A CASE OF RAPm GENERAL PARESIS AXD ATAXY DEVEL- OPIiSG TOGETHER. Thomas J. B., married, aet. 51, clerk, no insane relatives; first attack of insa nit}' ; supposed to depend on intemperance, although he had been temperate for the last two years. A THE GALLOPING FORM. 8 1 slight attack of depression, lasting one week, occurred when he became teetotal. He has had two severe falls, with no symptoms of local head injury. The first symp- toms of this attack occurred three weeks before admission, when he became strange in manner; unable to attend to his business ; sleepless, with exaltation of ideas ; believing himself a great man; able to compose poetry and paint pictures, at least, fit for the academy. He said his father was the son of a nobleman; was restless, boastful and en- croaching ; constantly moving about, willing to race or fight with the patients. His pupils were small but equal ; memory for recent events bad ; walk unsteady, legs be- ing thrown away from the body and falling on the heels ; patellar reflexes absent, says he can't feel the ground ; falls on closing eyes ; slight tremor of lips and hesitation of speech. He continued happy and contented with his pow- ers, making many pictures and filling reams of paper. In about a month he had divergence of eyes ; marked cere- bral giddiness when left eye was closed ; no evident changes visible in his discs. Since then bodily and men- tal weakness progressed rapidly. (Abstract, Savage on Insanity, p. 318.) A CASE OF GALLOPING GENERAL PARESIS. A man of 40, who had always been healthy, was taken ill and in a few weeks developed a typical case of general paresis with well-marked expansive ideas and delusions of grandeur and power. He was removed to the asylum and died there in ten days from a series of convulsive seizures which numbered ninety-nine in twenty-four hours. (Abstract, Jelliffe, Allgem. Zeitschreift fiir Psych., 55, 99-5-) GENERAL PARESIS OF THE GALLOPING TYPE. Louis F. G., married, ast. 50; artist, no history of in- sanity in the family ; and no previous attack of insanity. He had suffered from pleurisy with delirium two years be- fore ; steady in his habits ; cheerful and intelligent. Two months before admission he was irritable, nervous and de- pressed ; he lost his artistic power and forgot to complete his 02 VARIETIES OF GENERAL PARESIS. orders. Went from London to Paris and was unconscious of the difference between the cities. When he returned his bodily health was seen to be failing ; sleepless, poor appetite, difficulty in swallowing. He was clean in his habits ; had no extravagant ideas. He could not recognize himself in the glass, was suspicious, violent and obstinate about his food. The diagnosis was general paralysis in an early stage. Within two weeks he was so weak as to have to be kept in bed ; bed-sores developed and he died in six weeks. (Abstract, Savage, oj). c/L, p. 297.) The Double Form. — The circular type of paresis, or the double form, occurs in some cases, and most fre- quently where there is a history of heredity. This does not refer to the mental fluctuations after seizures, or to ordinar}' variability and emotional disturbances, but it is a distinct type, which characterizes a certain group of cases. The phases of the disease, in these cases, differ so widely as sometimes to cause the physician to doubt the diagnosis. The characteristic symptoms of ela- tion, either with or without an intermediate period of calm, may pass into a phase of depression, accom- panied at times by delusions of melancholia, even with suicidal tendencies, and sometimes with ideas of persecution. This may be followed by a fresh outbreak of excitement with violence, or exaltation and expansive delirium; and this, again, be succeeded by melancholia. The phase of depression has been known to con- tinue for months, in this way prolonging the life of the patient, for the periods of excitement, naturally, reduce more quickly the strength of the system. GENERAL PARESIS OF THE DOUBLE FORM. In a patient, exalted mania followed an attack of de- pression, resembling circular insanity, but instead of the melancholy returning, difficulty in articulation and epilepti- THE DOUBLE FORM. 83 form attacks supervened and he is now in last stage of the disease. (Abstract, Blandford on Insanity, p. 306.) GENERAL PARESIS OF THE DOUBLE FORM. Herbert F., single, get. 42, accountant, no insane rela- tives, first attack of insanity, no cause known. When admitted the symptoms had existed about six weeks. They began with nervousness and twitching, followed by depression and threats of suicide, but were soon replaced by great exaltation and extravagance. He believed himself rich and powerful and offered marriage to several ladies tongue tremulous, pupils equal ; hallucinations of hearing memory weak, sleeps well ; excessive patellar reflexes writing shaky. Five weeks after admission, both legs swelled and unhealthy-looking pustules formed. In two months he was variable, weaker in mind and emotional. In three months more he was melancholic and said he had offended God, but again became violent and emotional. In a 3'ear after admission he was quiet, no exaltation, looked like one suffering from melancholia with stupor ; circulation feeble, hands livid and congested. A little loss of expression, less tremor of tongue and hesitation of speech, yet he was wet and dirty. If seen for the first time now, he would hardly be recognized as a general paralytic. (Abstract, Savage, o^. cit., p. 326.) GENERAL PARESIS IN WHICH PARETIC SYMPTOMS ALTERNATE WITH IDEAS OF PERSECUTION. A hereditary degenerative patient was attacked by gen- eral paralysis. At about the same period manifested ideas of persecution, and attempted suicide. On admission in the following year he presented classical signs of general paralysis, also ideas of persecution and hallucinations of hearing. The symptoms of meningo-encephalitis disap- peared, while delusions of suspicion increased. Psycho- motor hallucinatory delusions of general and genital sensi- bility were added and he attacked his " persecutors" with deliberate violence. Two years later he had two epilepti- form attacks and signs of general paralysis reappeared in 84 VARIETIES OF GENERAL PARESIS. a more serious form, delusions of persecution vanished. Again the paralytic symptoms retrogressed and the delu- sions revived. In three years more his mental faculties had declined in vigor and the persecutory insanity had pro- gressively lost in activity and cohesion. (Magnon, Jour- nal of Mental Science, Vol. 53, p. 381.) GENERAL PARESIS OF THE ALTERNATING FORM. J. B., a countr}' laborer, with a history of alcoholic ex- cess and hereditary taint. On admission he was melan- choly, not inclined to conversation or to answer questions. He had the delusion that no one would employ him and was so miserable that he secluded himself and would not go out of doors. He feared that something was going to happen to himself and famil}- and refused food. His pulse was 120, with no physical symptoms to account for it ; no nervous phenomena ; pupils natural in size and out- line, but sluggish ; tongue protruded a little to the right side ; his general condition, pallor, want of muscular tone and anemia. A curious fact was that his despondency came on towards evening and had disappeared by morn- ing. He did not sleep well, was fidgety, restless and would not keep in bed. He was sent to work in the garden, became more cheerful, less restless and appeared convalescent, but two weeks later was nervous, frightened and tried to get out of the window at night. Nervous twitchings were now observed around eyelids and mouth ; his voice, at first melancholic, was now emotional and trem- ulous ; he was facile, easil}' diverted from one subject to another, but peculiarly sensitive in his feelings. Later the depression disappeared, he showed temper and impatience ; he was now reported as gaining strength, and improved in his mental condition, but twitching around eyes and mouth was still present. He was discharged much improved and again admitted in three months. He is now decidedly paretic, soon gets tired in walking and staggers ; his words are interrupted ; there is a quivering of the lower lip, even when the mouth is closed. Pupils normal, except that they remained dilated for two or three months. He is now MELANCHOLIC FORM. 85 violent and abusive. (Abstract, Campbell Clark, Mental Diseases, p. 217.) General Paresis of the Melancholic Form. — One of the types of general paresis, first described by Baillarger, is that with symptoms of melancholia and h3-pochon- dria. In the place of the symptoms of elation in the first stage, there is a feeling of anxiety and forebod- ing. In these cases it is more than a passing feeling of depression of spirits, which is so frequent in the prodromal stage. The symptoms are so like those of a true melancholia that the history presented by the friends of the patient must greatly influence the diagnosis, until such time as a congestive attack, or some somatic sign, occurs to give assurance as to the nature of the malady. After a time, in some cases, the ordinary course of the disease is followed, in others the symptoms of mental depression persist to the end. The hypochondriacal form of the disease is marked by headache, defective circulation, vaso-motor dis- turbances and various abnormal sensations, referred chiefl}- to the internal organs. Associated therewith are the mental conditions of despondency, languor, inattention and distress about unimportant matters. Actual pain in the epigastric region may be com- plained of for some time, indicating, as some believe, an involvement of the great sympathetic nerve. Hal- lucinations and illusions of a disagreeable character are sometimes added to the other symptoms. Clouston believes that almost all of these patients suffer from some organic visceral disease, or func- tional disturbance, which transmits sensations that are disagreeable and depressing. In examining his pathological register, he found that nearly all ot his cases of general paresis who had had tubercular disease had been melancholic. 86 VARIETIES OF GENERAL PARESIS. A CASE OF THE MELANCHOLIC FORM WITH TUBERCULAR DISEASE. G. K., a man, had the fixed melancholic delusion that a man was inside of him, who annoyed him constantly and thus made him depressed. Death showed tubercular dis- ease of the intestines. (Abstract, Clouston, Mental Dis- eases, p. 400.) A CASE OF THE MELANCHOLIC FORM WITH BRONCHITIS. A cabman who was very happ}- in the supposed posses- sion of thousands of pounds suddenly became melancholic, declared himself a beggar and cried bitterly. Upon exam- ination he was found to be suffering from bronchitis. Reflex action was so dulled that he had no cough and felt no pain. As he improved his delusions of grandeur re- turned ; upon relapse the melancholy state at once came back, but at last he recovered from the bronchitis and was again the happy possessor of his thousands (Clouston). The author adds: "Whenever I see a general paretic dull, now I always search for an organic visceral cause and usually find it." GENERAL PARESIS OF THE MELANCHOLIC FORM. The patient never presented symptoms of excitement or exhilaration before admission, and since then the mental state has been one of depression ; he sees people at night climbing into the window or door of his room; they are his enemies and try to take pictures of him. At other times, they pound his feet black and blue and, in evidence, he begs you to examine them for yourself. At other times, he hears them shouting to him to come out and de- fend himself if he can. He believes they are the attend- ants, who disguise themselves at night, and says he would kill them if he could, and, in fact, he tries to whenever he gets a chance. He had an epileptoid seizure soon after admission and was in a partial hemiplegic condition for nearly three weeks. (iVbstract, Stearns, Mental Diseases, p. 484.) MELANCHOLIC FORM. 87 A CASE OF GENERAL PARESIS OF THE MELANCHOLIC TYPE. John C, married, aged 47, merchant; no insane relatives. First attack of insanity, which had lasted six weeks, caused by loss of money, and anxiety, and began with the loss of identity. He refused to take food because he believed he could not afford it, and because he thought people were trying to poison him ; after admission, he was reported as silent and obstinate, refusing his food, negligent of his person and sleepless ; he had to be fed arti- ficially ; and he had a convulsive seizure in the early part of his illness. He slowly lost strength, but remained per- verse and melancholy. The cause of his physical deteri- oration and of the difficulty in breathing which came on, was unknown. Died in about three months. (Abstract, Savage, o^, cit,, p. 314.) AN ODD CAPRICE IN A MELANCHOLIC PARETIC. A patient, prevented from suicide by his wife, drew dia- grams of his tombstone, whose inscription recited all his achievements, and sang the praises of his wife for saving the life of so valuable a citizen. (Abstract, Spitzka on Insanity, p. 199.) A PECULIAR DELUSION OF ONIONS AND SARDINES, IN THE HYPOCHONDRIACAL TYPE. A patient who could not eat or digest, and who had not a penny, according to his statements made during the hy- pochondriacal period, awoke one morning with the project to get up a monopoly of the entire sardine and Bermuda onion trade in the world, and having, as he alleged, se- cured it, proposed to eat all the sardines and onions him- self. (Abstract, Spitzka, op. cit., p. 200.) A CASE OF GENERAL PARESIS OF THE MELANCHOLIC TYPE. One patient who had many of the commonest delusions of melancholia, thought he was going to be arrested, that people were going to injure him, that they were malign- 88 VARIETIES OF GENERAL PARESIS. ing and going to rob him. Yet he was not melancholic as other men were. He never refused his food, but was very fond of it, and ver}' particular as to what he ate. He had a good opinion of himself, very vain of his personal appearance, and, with all his melancholy ideas, was often quite cheerful and chatty. His mind was dull, lethargic and void of excitement during the whole illness. (Ab- stract, Blandford, of. ciL, p. 289.) Spinal General Paresis. — There are several groups of cases termed the spinal varieties of the disease, in which there are various implications of the cord. Only to a limited degree should they be looked upon as ascending and descending systemic affections, but rather as general diffuse affections depending upon the involvement of the whole nervous system. It is not strange, therefore, when we consider that the process of degeneration is one affecting the entire nervous tissues that in a certain proportion of the cases the form of the disease should be first mani- fested in some portion of the spinal cord. Bevan Lewis ^ has divided the cases of general paresis as the}- relate to the cord into three varie- ties: (i) In a majority of the cases, as the only evidence of spinal implication, we find diminished cutaneous sensibility and sluggish knee-jerk, alternat- ing at a later period with increased knee-jerk, usually as the direct sequel to a congestive seizure. Later in the disease paretic symptoms may preponderate, but the cerebral implication throughout is always the more emphasized. (2) The tabetic group, with most of the symptoms of tabes dorsalis. Yet we usu- ally witness complete subsidence of the special spinal S3'mptoms when the full development of the cerebral symptoms is established; or what is not infrequent the anesthesia and ataxy may even be 'O/. cit., p. 556. SPINAL FORM OF GENERAL PARESIS. SPINAL GENERAL PARESIS. 89 replaced by spastic paraplegia. (3) The group of spastic cases in which symmetrical descending scle- rosis of the lateral columns is early apparent and continuous; usually as the sequel of convulsive seizures and especially frequent in those subjects who have been addicted to alcoholic excess. The best observers have invariably failed to find that the great Wallerian law of degeneration applies to the pathological reductions of general paresis.^ IMPLICATION OF THE LATERAL COLUMNS. Francis R., single, aged 30, medical student, no history of insanity, first attack, lasting six months; said to have followed excesses and to have had former attack of syphilis. The first symptoms were, change in disposition, oddness in behavior and absence of mind. He had always been vain about his appearance and powers and this developed into extreme exaltation ; he thought himself a perfect para- gon, although he had not passed even his preliminary exam- ination. On admission he was of medium height, squarely built, with bright malar capillary congestion, his walk jerky, patellar reflexes exaggerated, pupils unequal, the right one larger, both reacting to accommodation, but slightly only to light. For twelve months he slowly devel- oped weak-mindedness, great hesitation in speech, extreme facial and lingual tremor, a nervously irritable appear- ance ; no control over bladder and rectum ; indifferent to ^ One of the earlier views of paretic dementia, when it was the termi- nation clinically of posterior sclerosis, was that the degenerative conditions in the spinal cord continued through the motor tracts all the way to the cerebrum and to the cerebral cortex. This is certainly not the correct view. A number of years ago I had for several years a case of posterior sclerosis under my care in private practice. The patient became paretic and went to the Pennsylvania Hospital for the Insane, and subsequently to Danville, where he died. The body was sent to Philadelphia, and a post-mortem was made, and twenty or thirty sections from the cord, and all the way to the cortex, were examined under the microscope. Similar cases have been recorded. The disease perhaps ascends so far as the cord is concerned; but the cerebral condition is only a localized expression of a general condition. The disease does not usually extend anteriorly beyond the oblongata and pons. (Mills, C. K., Nervous and Mental Diseases, Vol. 18, p. 85.) go VARIETIES OF GENERAL PARESIS. his surroundings, neither reading nor associating. One year after admission he was unable to walk alone, could not articulate a single word, very wet and dirty, legs be- coming contracted. He died in about three years after onset of disease. (Abstract, Savage, op. ciL, p. 319.) GENERAL PARESIS WITH LATERAL SCLEROSIS IN A WOMAN. Edith C, married, ast. 35, printer's wife, no history of insanity, lirst attack, of six weeks' duration, had no chil- dren. When admitted the first symptoms were accusations against her husband. She became incoherent and restless, wandering about in her night-dress, saying her husband wanted to poison her ; she was excited, had exalted ideas about riches ; thought there was chloroform in her hus- band's brain, that he was mad; that she was a duchess. On admission she had hallucinations of taste, pupils small but equal, slept badly, walk shaky, reflexes greatly exag- gerated, no change in optic discs. After admission, she steadily got more feeble in gait, more tremulous in speech, with difficulty in swallowing, and loss of power over rec- tum and bladder. In about two months she had an epi- leptiform attack with general convulsions, but the symp- toms were most marked on right side ; she lost power and sank. (Abstract, Savage, oj). ci'L, p. 320.) IMPLICATION OF POSTERIOR COLUMNS. GENERAL PARESIS PRECEDED BY LOCOMOTOR ATAXIA. G. A., a man of 50, who had had locomotor ataxia for seven years, began to be maniacal, sleepless, and to have delusions of grandeur. Imagined he was an earl wath millions ; wrote fifty letters a day, ordering everything imaginable ; and invited the Queen to dinner. His speech was affected by the characteristic tremble of the lips, the shuffle and thickness in the articulation of long words and sentences. He passed through the second and third stages of the disease and died in eighteen months from the time of the beginning of the mental symptoms. (Abstract, Clouston, op. c/L, p. 389.) SPINAL GENERAL PARESIS. 91 Fig. I. GENERAL PARESIS FOLLOWING LOCOMOTOR ATAXIA. A chaplain in a Welsh prison had locomotor ataxia of very marked and progressive character. He kept his ap- pointment in the prison for several years. After ten years, he showed signs of exaltation. These became progres- sive, he began to run down rapidly, went into general paralysis and died eighteen months after the latter symp- toms developed. (Abstract, Down, Transactions of Ninth International Medical Con- gress, Vol. 5, p. 405.) GENERAL PARESIS FOLLOW^ING LOCOMOTOR ATAXIA. A patient having locomotor ataxia finally showed mental symptoms in the form of ex- citement and delusions of gran- deur. No mental symptoms had appeared until a year after the motor symptoms, but there had been mental weakness for some time prior to the appear- ance of the more pronounced mental symptoms. (Abstract, Stearns, 0^. cit., p. 513.) GENERAL PARESIS OF THE TABETIC FORM. c. dier, three B., aet. 39, married, sol- station in tabetic form of gen- father was insane for ,, . ;^^-^ ^--^sis. Showing tendency to over-extensiou months. History of of the knee-joint; needing- aid of both , -r T , y , sight and supportto maintain balance. present attack : unsettled, and could not fix attention on his work, did stupid things in the house ; although wife and children were starving, spent what money he had in useless articles and gave large orders for things for which he could not pay. On admis- sion, imagined he was very wealthy. He was restless, 92 VARIETIES OF GENERAL PARESIS. talkative and excited ; he could not sleep at night, owing to imaginary insects annoying him (hallucination of touch). His left pupil larger than right, both reacting to light ; tongue tremulous ; sensation normal ; reflexes not im- paired ; special senses healthy. Progress of case : Exal- tation well marked, says he is a magnificent writer, while in reality he can barely write his own name. There is considerable mental enfeeblement, articulation correct, tongue tremulous ; left pupil sometimes larger and some- times smaller than the right ; outline sometimes irregular. There are tabic symptoms. Standing with feet together and eyes shut, he sways about and tends to fall. A year after admission : Mild exaltation, showing itself in con- tented expression, and not in well-marked delusions ; no excitement or depression. Enfeeblement is well marked, seen in being easily controlled, in want of self-assertion, in absence of mental vigor ; memory is impaired, espe- cially for names of places. The symptoms of locomotor ataxia are well marked. With his eyes open, has difficulty in walking and cannot stand unsupported ; his lower limbs little better than arti- ficial limbs ; coordination of arms and hands not impaired. Sensation to pain and tovich impaired in lower extremities, much less so in upper; plantar reflex impaired, tendon reflex abolished, right pupil larger than left, contract to accommodation but not to light. (Abstract, Campbell Clark, of. c/'t., p. 219.) A CASE OF GENERAL PARESIS FOLLOWING LOCOMOTOR ATAXIA OF SYPHILITIC ORIGIN. Alfred S., single, 45 ; no neurotic history; syphilis six- teen years ago, but no serious secondary troubles. Six years ago locomotor ataxy developed and was treated. Symptoms of mental disorder have appeared during the past week. He had been exposed to wet and cold a good deal recently. He became excitable and irritable and sleepless and noisy at night. He wrote endless letters, tore up books ; w^as going to reform the world, to suppress the House of Commons, to blow up everything with dyna- SPINAL GENERAL PARESIS. 93 mite. He has had hallucinations of hearing for a month, and shooting pains in his legs. He had frequent erec- tions and emissions; pupils at times equal, small at others, the left larger. Six years ago he had convergence and diplopia, cured by the use of mercury: general and color vision normal ; pupils reacting both to light and accommo- dation ; patellar reflexes absent; walk ataxic. On ad- mission, he had all the most marked symptoms of ataxia and of general paralysis of the insane and no treatment seemed in any wav to affect him. (Abstract, Savage, Transactions of Ninth International INIedical Congress, Vol. 5, p. 939.) TWO JUVENILE CASES IX WHICH THE FIRST MANIFESTA- TIONS OF THE DISEASE WERE IN THE CORD. Female, ast. 23, ill two vears, in a helpless condition, unable to walk or stand up, with violent tremors, marked affection of speech, inequality of pupils and Argyll-Rob- ertson phenomenon, demented, loss of control of bladder and rectum, marked general anesthesia and slow re- flexes, suggesting medullary lesion. Also a youth, aged 19, ill on and off for four years, finalh' went under Char- cot with paraplegia, leading to a diagnosis of " organic lesion of cord." Under ergot and actual cautery, the para- plegia disappeared, but later there was anesthesia of the face and arms. Then, rapidly appeared, weakness of legs, emaciation, affection of speech, tremor of lips, un- equal and inactive pupils, wet and dirty habits, etc., and early death with post-mortem evidence of general paralysis (Joffroy). CHAPTER VIII. VARIETIES [continued^. General Paresis with Simple Progressive Dementia. — Some cases exhibit simple weak-mindedness through- out the whole course of the disease, without any inter- mediate stages of excitement or depression. This may follow in cases beginning with convulsions, or it may develop without any appreciable cause. There is con- siderable variation in the manifestations. It may show itself in simple loss of memory, in an inability on the part of the patient to adjust himself to his surround- ings, or in a childish or emotional disturbance. Some cases are querulous or nervous, others are boyishly frolicsome. The ph3'sical symptoms take the usual course. GENERAL PARESIS OF THE DEMENTED TYPE. G. C, aet. 50, a quiet-living man. First showed irresolu- tion, want of keen interest, and forgetfulness ; he could not realize necessity for working in order to live, and became irritable when pressed to work. Then his mind showed clear signs of enfeeblement and facility. He would believe silly stories ; could not converse connectedly, had few likes or dislikes. His speech was thick, and lips quivered when he began to speak. His walk was not firm ; in trying to turn around sharply he did so uncer- tainly, and could not walk on a chalk line, or stand steadily on one leg. Nearly all his symptoms are negative. He had a gentle kleptomania ; he would automatically fill his pockets with acorns, rags, etc., and did not seem to care when they were taken from him. He died in six years of pure exhaustion, absolutely paralyzed, not having made an articulate sound for a year, and not having voluntarily 94 SIMPLE PROGRESSIVE DEMENTIA. 95 used a voluntary muscle, lying on a water bed and lead- ing a merely vegetative life. Such cases are apt to live a long time ; they are not usually caused by a dissipated or excited life, and are of a calm, phlegmatic temperament. (Abstract, Clouston, Mental Diseases, p. 391.) A CASE OF GENERAL PARESIS OF THE DEMENTED TYPE WITH EPILEPTIFORM CONVULSIONS. A traveling salesman was regarded in good health, until his return home on one occasion, when he appeared dazed and unable to give an account of himself, except that he had been robbed in a sleeping car in New York. It was then found that he could not tell an occurrence ten minutes after it was past. On admission, he was good-natured, facile and satisfied. He did not mind remaining as long as we should choose, though he left a sick wife and little daugh- ter dependent on friends for support. No impairment of gait ; never had been excited, was eminently quiet, good- natured and satisfied. He had epileptiform convulsions, defective articulation, placid expression of face, impaired memory and weakening mind and entire satisfaction ; muscular twitching of face and tongue, but hands and legs were firm and he walked without difficulty. He had a convulsion once a month and finally died from the effects of one, having never been excited, depressed or emotional. (Abstract, Stearns, Mental Diseases, p. 489.) A CASE OF GENERAL PARESIS OF THE DEMENTED TYPE WITH HEMIPLEGIA. W. B., aged 32, father has had apoplexy; patient had left hemiplegia of which a faint trace remains in the left leg ; fairly good personal history. The attack of hemi- plegia came on when he was at work in a coal pit, but he was able to walk home though his leg was somewhat stiff. His speech became slow and thick ; he became weak and childish, this mental change being noticed before the onset of the hemiplegia. The pupils were at an early stage unequal and the reactions impaired. There is slight facial deficiency, tremor of tongue, slight tremor of lips and 96 VARIETIES OF GENERAL PARESIS. he exhibits other nervous symptoms of general paralysis. This is a very slow case, childish contentment, no real exaltation. (Abstract, Campbell Clark, Mental Diseases, p. 220.) A CASE OF GENERAL PARESIS OF THE DEMENTED TYPE OF SYPHILITIC ORIGIN. Patient male ; ast. 45 ; tailor. Family history negative ; syphilis. Patient first noticed some weakness in his left hand, which gradually developed into a paresis, so that he could not carry on his work. Paresis gradually show^ed itself in his left leg. Examination shows left hemiplegia, with marked intention tremor, with paralysis agitans of left hand ; reflexes exceedingly exaggerated ; expression- less face ; fine tremor of face and tongue ; speech, slow and clumsy, with inability to pronounce "truly rural," etc. ; no delusions of grandeur, etc., but some slight de- mentia and contentment with his condition. (Fisher, E. D., Journal of Nervous and Mental Diseases, Vol. 18, p. 825.) A CASE OF GENERAL PARESIS WITH SIMPLE PROGRESSIVE DEMENTIA. E. M., married, cet. 46, merchant, no insane relatives, mother died paralyzed, one brother died of apoplexy. This was the first attack ; cause, great money losses and anxiety about his family. He had been temperate and hard-working ; he had a convulsive seizure two and a half years before he was considered insane. The present ill- ness began with incoherence and confusion of thought and speech ; he was unable to enter into rational conversation, and had a vacant expression of face. On admission, he was stout and expressionless, with feeble power of reaction and negligent of his personal appearance ; optic discs greatly atrophied ; reflexes exaggerated ; and nearly all the mus- cles, both of face and limbs, unduly irritable to the elec- tric current. He improved bodily, gaining fourteen pounds in seven months but mentally became weaker; right pupil large, and reacted to accommodation but not to light ; JUVENILE GENERAL PARESIS. 97 great tremor of facial muscles and hesitation in speech. Athough gradually getting weaker in mind, at times he brightened up, and could recognize relatives and under- stand his position as a patient in an asylum. Such periods are often followed by convulsions or exaggeration of men- tal weakness. In two and a half 3'ears he had become ver}'' thin, and there was contraction of his legs and he was unconscious most of the time. At the end of another month he had a series of severe epileptiform fits and died. (Abstract, Savage on Insanity, p. 312.) Juvenile General Paresis. — General paresis in early life, i. e., under the age of twent}", is very rare and no cases of it are to be found in medical writings, until within very recent 3'ears. Most of the cases have been repoi'ted by English and German observ- ers, although a few are to be found in French and Russian literature. This form of the disease has been variously termed developmental, premature, early, precocious, and juvenile general paresis. Clouston-^ gives an account of two girls placed under his care in 1890. He says that in both, the first symptoms of the disease had been manifest at fifteen years of age, and that both followed the usual course till they died, one at seventeen, the other at twenty. Both were undeveloped in form and appear- ance, neither had ever menstruated, and both suffered ^ As regards the occurrence of general paralysis at this period of life of which Dr. Wiglesworth speaks (puberty), I admit I was extremely skeptical of the first case. One's whole ideas of general paralysis were contrary to its occurrence taking place at this earh' period of life. I, along with Dr. Maudsley, had attached very great importance to sexual excess in the causation of general paralysis ; and here we had cases where undoubtedly there had been nothing of the kind in any shape or form. Then it seemed extraordinary that every other possible cause of general paralysis was absent, in these particular cases. On the whole it had the effect on my mind of almost revolutionizing my ideas of general paralysis. To begin with there were great doubts expressed as to whether they were cases of general paralysis or not ; but I think the evidence is so striking, and in Dr. Wiglesworth's paper it is of so conclusive a nature that such cases will not be questioned in the future. (Clouston, Journal of Mental Science, 18930 98 VARIETIES OF GENERAL PARESIS. from hereditary neuroses, and hereditary syphilis. The pathological appearances found in the brains of both, together with the symptoms during life, left no doubt as to the nature of the disease. In almost all cases there are premonitory symptoms in a change of disposition, a loss of interest in sur- roundings, diminished energy, morbid sensitiveness or some other mental change marking a weakened nervous energizing. Delusions of grandeur are seldom present, and far the larger number affected are girls. The disease occurs as one of the groups of the neuroses of development, and subjects are usually possessed of a family history of neuroses, insanity and frequently syphilis. A CASE OF GENERAL PARESIS OF THE JUVENILE TYPE. A female child, aet. 13, ten months ago became dull in mind. During the course of the case she had several falls and hurt herself, but it was noticed that she was dull before she had the falls : she was the tifth child of her parents ; the four previous children are alive and healthy. Subse- quently to the patient's birth, two pregnancies ended re- spectively in a still-birth and miscarriage. When seen, she presented tvpical physical signs of general paresis. Her father died with paralytic symptoms attributed to syphilis and the mother died a year later with similar symptoms. The patient was not conscious of being ill ; she said she was always happv. (Abstract, Norman, Journal of Mental Science, Vol. 39, p. 307.) A CASE OF GENERAL PARESIS IN THE ADOLESCENT PERIOD. J. McC, aet. 19, both parents very intemperate ; patient naturally weak-minded, but had been to school ; fifteen months before admission he had a fall on his head and lay unconscious for four days in convulsions : was said never to have fully recovered his mind after this. On admission he was in a condition of advanced dementia. He could not PUte VL JUVENILE GENERAL PARESIS. A case of the Juvenile Form recently under observation for a time at tVie Philadelphia Hospital. The patient was taken from the Institution and afterwards disc.ppeared from view. From a photograph kindly loaned. JUVENILE GENERAL PARESIS. 99 answer a single question rationally ; excited and noisy ; muttering an incoherent jargon ; wet and dirty. Died in six months. (Abstract, Wiglesworth, Journal of Mental Science, Vol. 39, p. 357.) A CASE OF GENERAI. PARESIS OF THE JUVENILE TYPE. M. E. M,, girl, aet. 15, parents healthy and temperate, father aged 50, mother 42, had been married eighteen years. The patient was the second child in the family; she was one of three survivors out of thirteen pregnancies, and of the eight female pregnancies patient was the only survivor. Two of the others were miscarriages, two were still-born, one died, aged two weeks, and the other two died of scarlatina. Of the five male pregnancies, one died, aged five weeks, in a fit, one aged two of some unknown cause, another aged two and a half years of scarlatina. There was no other evidence of syphilis, but the above suggests it. No history of nervous disease in the family. Patient was bright until eleven years old, when she fell, striking her head ; unconscious for two hours and in bed with headache for several days. Some months after, she developed weakness of the limbs. A year after accident she was noted to be getting dull, losing her memory, and from that time on her mind gradually faded away. During three or four years previous to admission she had several falls, apparently the result of paresis ; once, she fell down a whole flight of stairs and had convulsions during the following night. On admission intelligence very defective. Answers "I don't know" to all questions ; powers of atten- tion and understanding deficient ; unable to look after her- self ; inattentive to the calls of nature and sometimes noisy. A well developed child, signs of puberty slightly marked ; had never menstruated ; pupils slightly dilated and of normal reaction ; viscera were sound ; considerable de- mentia ; usually quiet and tractable ; took no interest in her surroundings ; when touched, however, cried and seemed frightened : much loss of memory and could answer correctly only the simplest questions ; wet and dirty in her habits. After three months she was sent home lOO VARIETIES OF GENERAL PARESIS. in the same condition ; readmitted five months later a com- plete wreck, mentally and physically ; could not stand alone, could not tell her own name, seemed to understand nothing that was said to her. Continually moved to and fro in her chair, uttering a crowing meaningless laugh and, when touched, she cried loudly and continuously ; tongue tremulous, also lips ; speech hesitating and ejaculatory ; was soon confined to bed ; limbs became strongl}' flexed ; screamed a good deal, but showed no signs of intelligence. All evacuations were passed under her ; very emaciated ; bed-sores developed. No convulsions were noted. Died aged i6. (Abstract, Wiglesworth, loc. cit., p. 359.) GENERAL PARESIS FOLLOWING ACCUSATION OF THEFT. AN ADOLESCENT CASE. A young woman of 18, while going to a shop, dropped some money and a man saw her pick it up. He accused her of stealing it and gave her in charge. When taken before the magistrate, she was unable to make a reply, and was sent to prison for fourteen days. On returning home, her father found her entirelv altered : talked of her wealth, etc., and he was told she had a kind of fit in prison. (Abstract, Sankey, Mental Diseases, p. 292.) A CASE OF JUVENILE GENERAL PARESIS AT THE AGE OF NINE YEARS. Raymond reports the case of a girl, ast. 9, who showed progressive intellectual weakness, almost complete loss of memory, sensory motor disturbances, localized on the right side, disorder of speech and trembling of the lips, inequality of the pupils, with abolition of the pupillary reflexes, n3'stagmiform movements and slight strabismus, double, non-congenital, pigmented retinitis, and exaggeration of the reflexes. The psychic symptoms were temporarily benefited by mixed treatment. The disease was thought to be one of organic cerebral origin and general paralysis was diagnosed. She died several months later from a tuberculous broncho-pneumonia. Her brain was typical JUVENILE GENERAL PARESIS. lOI of general paralysis. (Abstract, Philadelphia Medical Journal, Vol. 5, p. 680.) A CASE OF GENERAL PARESIS IN A GIRL NINE YEARS AND THREE QUARTERS OLD. E. E. C, female, admitted March, 1894. It was the first attack and of five months' duration ; she was dangerous, but neither epileptic nor suicidal. No history of alcohol, phthi- sis or insanity. Born January, 1884. Cause of insanity said to be a fall which she had in April, 1893, but no history of her head being injured and she returned to school in a few days. October 14th she was admitted, stated to be suffer- ing from hydrocephalus and chorea ; she had been " rather strange" but previously had been a child of average intelli- gence — able to read and write, etc. On admission to hospital she was pale and thin, looking older than nine years ; weak intellect, with slight choreic movements. November 7, she has had alternate excitement and depression ; pupils unequal, and general nutrition improved. November 18, constantly screaming. Her nightly temperature rose on a few occasions to 99° and once to 100.4°. After leaving hospital she began to show symptoms of insanity, and had sudden fits of crying ; at times, restless and violent, at others silent and depressed ; she did not recognize her parents ; thought she had lost her money. Her speech had begun to fail when admitted to asylum. She was anemic, pupils semi-dilated, right reacts normally, left is fixed ; head of large size ; tongue straight, slightly furred ; palate not unduly arched ; body well nourished ; heart and lungs nor- mal ; pulse 104, knee-jerk present, no clonus, she showed profound dementia, no reply to questions. "Mother," the only word she says. She constantly cries without appar- ent cause ; vicious, bites and scratches those around her, requires feeding and is unclean. April 21, menstruated; in the same demented state : grinds her teeth ; difficulty in swallowing ; deteriorated physically until September 18 when she had epileptiform convulsions chiefly affecting right side and followed by paresis, which passed off on September 23. She walked with an inclination of her I02 VARIETIES OF GENERAL PARESIS. body to the right, left pupil dilated, right contracted. Oc- tober 26, dilatation of left pupil and flattening of left side of face ; right pupil semi-dilated and reacts sluggishh*, no reaction in left. December 10, more feeble, grinds her teeth, is sucking and picking at the bed clothes, can swallow only a little food at once. February 7, she is almost moribund. She takes no notice of anything ; swal- lows with great difficulty and regurgitates most of her food ; grinding her teeth and screaming out ; yery dirty. Died in February, 1895. (Abstract, E. L. Dunn, Journal of Mental Science, \'ol. 41, p. 482.) GENERAL PARESIS IN TWO SISTERS AT EARLY LIFE. Ida, was healthy as a baby and seemed in every way normal ; she was eyen considered yery bright, but when aged about 10 she was thought to be growing lazy ; instead of playing would sit about the house in an apathetic way. She frequently complained of stomach-ache, but had no vomiting. On account of this trouble she was kept out of school. When aged about 11 she began to be unsteady in her gait and had to be guided around. " Two years we dragged her around, two years she sat in a chair and two years she was in bed." When aged 14 her legs had a tendency to be drawn up, and later this became so marked that even passive extension was difficult ; a similar condition also appeared in the arms. For the last two years she could not sit up in a chair ; her voice became coarser and speech indistinct, at the end turning into a mumble. The mental condition approached a complete dementia and a year before death she knew no one. She lay in bed contracted, untidy, mumbling, picking at her bed clothes and unable to help herself in any way. There was no excitement or delusions, and no convulsions except a series of them shortly before death. She died in con- vulsions a week after their onset. Rosa, now 19 years old, has been a healthy child and of average intelligence up to her fifteenth year, and has been considered feeble-minded by her famil)'^ since her sixteenth year. She has had no excitement, delusions or JUVENILE GENERAL PARESIS. I03 hallucinations. She first showed an inability to follow school work ; then a lack of interest in, and an inability to understand, things, however simple. She could do cro- chet work, but no one could teach her a stitch different from the one she had always known. For two or three years her gait has been changed and she is somewhat un- certain ; her speech gradually became altered. She has had no convulsions. After arriving at the hospital, she was not clear where she was, and did not mind her sister's leaving her. Afterwards, she said she was homesick, but was easily made to forget it. She was quiet and orderly, and absolutely unable to appreciate her surroundings. When asked to, she described a picture in a very elemen- tary manner; her behavior was often silly. During an examination she would tell a perfectly irrelevant incident or laugh convulsively. She could recite poems she had learned at school, but did not grasp their meaning, for she often left out lines and words without noticing it. When asked to read, her mistakes were characteristic. Individ- ual letters and most small words were correctly read when shown alone ; longer words could not be read even after spelling, or they were mispronounced, as "laze" for lizard, " colking " for choking, etc. Figures could be read, sometimes four together, but never more. Writing showed mental defects analogous to those expressed in reading and also tremulousness, at once suggesting general pare- sis. She could not multiply correctly with numbers larger than four, and she did multiplication better than addition or division. All that she knew depended entirely on some well rooted association ; no amount of practice improved her. (It should be remembered that she had been to school up to her fifteenth year.) The gait was tottering, the legs held far apart and stiffly ; walking as though she was flat- footed and wavering from a straight line. The arms, during walking, were held away from the body, as if for balancing. She could stand with eyes closed and feet together, but not at all on one foot. Her speech was indis- tinct, monotonous, high-pitched and had a certain vibra- tion to it ; some words are slurred over, and there is a I04 VARIETIES OF GENERAL PARESIS. coarse tremor about mouth and tongue ; the face is some- what one-sided ; the patellar reflexes have been exaggerated and there has been patellar clonus but only slight ankle clonus. The reflexes in the arms were increased; the pupils have been unequal and do not react to light or ac- commodation ; she perceives tactile impressions well, but pain sensations not so well ; she could not feel the prick of a pin or the faradic or galvanic current. She shows no signs of hereditary syphilis. These two girls are the youngest of a family of seven. The others are healthy and normal, and show no signs of hereditary syphilis. The mother had no miscarriages. The father, a Dane, has been unable to work for twelve years, although only sixty-one. He often became dizzy and could not direct his hands properly. Six years ago, he suddenly became pale, fell down and was weak on one side. He recovered completely. He often falls, partly because he gets dizzy, partly because he stumbles. Last year, he had two " boils " on his forehead containing dead bone ; he has been irritable for years ; denies syphilis ; he had considerable facial tremor ; speech not altered ; tongue normal ; handwriting tremulous ; muscle power fair and equal on the two sides ; gait tottering but not ataxic ; he stood well with his eyes closed ; knee-jerks are diminished ; pupils normal ; arteries are thickened. Evidently it is not general paresis. (Abstract, Hoch, Aug., Journal of Nervous & Mental Diseases, Vol. 24, p. 68.) A CASE OF PRECOCIOUS GENERAL PARESIS. A boy of neuropathic heredity, both paternal grand- parents having had paralytic troubles, a cousin having been insane and his father formerly intemperate. No evidence of syphilis. During childhood was healthy, and a good scholar. At age of 14 he was put to work. After a month, his intelligence began to fail, had to be told every- thing that he had to do, wrote badly, could not make arithmetical calculations, seemed changed, taciturn and silly, stammered at times, hands trembled when tired. On admission, he had wet his bed for two months ; backward JUVENILE GENERAL PARESIS. I05 in physical development ; slight evidences of puberty, al- though 17. Expression dull, walk clumsy, all movements awkward. His mind much enfeebled, seemed apathetic and indifferent. Memory poor, no delusions ; tremor of tongue and lips extending at times to other facial muscles ; articulation imperfect, especially when tired and with the lingual consonants ; tremulous hands, clumsiness of hand- writing with a tendency to omit and misplace ; inequality of pupils ; attacks of formication, beginning in right foot and involving the whole right side ; headache, general muscular weakness, no localized paralysis, knee-jerk ex- aggerated. (Abstract, Charcot, Arch, de Neurol., March, 1892.) A CASE OF DEVELOPMENTAL GENERAL PARESIS. Annie H., admitted to Morningside, is the youngest of a family of four. The second eldest was a miscarriage ; the other two are healthy. The patient was a normal child up to the age of eight. She got on well at school, until she was eight when a bad stammer developed. She then did work around the house, but the stammer got worse. When aged sixteen she was noticed to be more stupid than usual and forgot things ; did not do her work well. These changes gradually increased ; four years ago she was sent to poor-house, until she came to asylum. She had required constant attention, had no attacks of excitement, no delusions, spoke less and less and stammer got worse. On admission, aged twenty-three, she was well developed ; absence of expression in face and eyes ; movements leth- argic ; there was difficulty in rousing her attention to questions, would smile in a meaningless way, without provocation. Emotionally she was happy rather than depressed. There was considerable muscular weakness, some incoordination and slight tremors of upper lip ; knee- jerk and other reflexes exaggerated ; pupils unequal, slightly irregular, and did not react to accommodation ; she had menstruated only once or twice when aged sixteen ; teeth not well shaped ; thickening of tibial bones, presum- ably of a syphilitic character. Since admission, she has lost 9 lo6 VARIETIES OF GENERAL PARESIS. flesh and strength, confined to bed, very helpless ; all the symptoms are now more pronounced. There have been slight rises in temperature with increased mental obscura- tion, never, however, reaching unconsciousness, regarded as congestive attacks. During them there is headache but no convulsive movements. She will not live many months more. ( Abstract, Middlemass, Journal of Mental Sci- ence, Vol. 40, p. 41.) General Paresis in Woman. — The disease runs a milder and longer average course among women, and remissions are less frequent. It occurs earlier in women and the fraction of female paretics under the age of thirt}' is nearly three times that of male paretics (Mickle). Recent statistics give the pro- portion of male and female cases as seven to one. Hereditary predisposition is frequent, and in fully one third of the cases syphilis is the etiological fac- tor, some writers placing it much higher. Spinal symptoms are less noticeable than in the opposite sex, and the ascending form is rare. Alteration of the menses, apart from that due to age, has been frequently noticed, but the influence of the climacteric, formerly so emphasized, does not ap- pear to have the importance attributed to it. The course of the disease does not differ, as a rule, from that generally described, euphoria being present in most cases, while excitement and expansive delu- sions, though not infrequent, do not reach the height common in men. Although paresis is so common among men of the higher classes, women of these classes, as stated elsewhere, are not frequently at- tacked; but when women drink much bad liquor and live excited, irregular lives, they are readily subject to the disease. Some writers speak of a form of the disease ob- served in late years, aflfecting man and wife at the PUte VII. GENERAL PARESIS IN WOMEN. GENERAL PARESIS IN WOMAN. I07 same time and which is called " conjugal general paresis." It has its explanation in a reciprocal S3'ph- ilization. A CASE OF CONJUGAL GENERAL PARESIS. A woman admitted at the same time with her husband, both fairly intelligent, and with a seeming neurasthenic confusional state ; wife had no motor symptoms ; husband, diagnosed as general paretic ; he rapidly went into an active maniacal state, delirious, persistent diarrhoea, died of ex- haustion in three months, a few hours after a convulsion ; died before being extremely paretic. The woman, although feeble-minded, went home, returned in a year, and later showed dementia, then motor signs, slight cerebral attacks, steady decline and death. (Abstract, Phelps, American Journal of Insanity, Vol. 53, p. 59.) GENERAL PARESIS IN A WOMAN. Mary A., married, aet. 36. Formerly an actress; no insane relatives ; present attack the first ; supposed cause, great anxiety and money troubles of her husband. First symptoms appeared nine months before admission. She became excited and incoherent for twenty-four hours and thereafter showed mental weakness. On admission, she had vacant expression, wanted to be dressed elaborately, think- ing herself a great person. When spoken to she replied by saying " jollv." She walked awkwardly; speech hesitating ; comprehension dull ; appetite good ; loss of power ov,er bladder and rectum. Within one month of admission she became nois}'', violent, destructive and re- fused to take food. An erythematous rash, followed by large bullae, appeared on legs ; she had subnormal tem- perature. She steadily lost strength and died. (Abstract, Savage, of. ci't., p. 302.) A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE IN WOMAN. Mrs. — , aet. 49 years. Four years ago consulted oculist for asthenopia, and especially for difficulty in accommo- dation. No mental symptoms were observed, although Io8 VARIETIES OF GENERAL PARESIS. at that time they were not carefully looked for. One year afterward, mental symptoms, considered of no im- port, were observed, she being exhausted by the care of an ill mother and sister. One year later still, she began to have attacks of loss of consciousness, similar to petit mal, after lying down or sleeping. She had several while standing, and thought she would have fallen but for sup- port. She remembered much less well than formerly ; was irritable, apathetic, indifferent, disinclined to exertion. She could not understand or remember clearly what was read to her, although she could talk of it in a general way. Her husband was surprised at some of her incorrect state- ments to the physician. He had noticed that she forgot where she put things, and what she was going to do. Showed less life and ambition in her face ; loss of physical strength, especially in her legs, noticed when going up and down stairs. After walking a half mile she became tired, and her gait became unsteady and tottering. She was dizzy at times, rarely had headache ; could not fix her eyes to read. Hands tremulous ; slight hesitation in speech, which her husband and she thought natural ; and articulation deliberate, almost sluggish. In spite of good appetite and hearty eating she lost sixteen pounds. I have not watched this case to termination but have no doubt of the result. (Abstract, Folsom, loc. cit.^ p. 17.) GENERAL PARESIS IN A YOUNG W^OMAN. Martha C, admitted, aged 20, the youngest of eight children. The second and third were still-born at the seventh month ; the fourth had deformity of the spine, and died five months after ; the fifth was a seven-month child and lived only two days ; the others were living and healthy except patient. Five years ago patient's develop- ment came to a standstill, finally retrogression occurred, without any violent physical or mental course. First, alteration in speech, which became thick and slow ; she also became stupid. All these symptoms grew more pro- nounced, she remained at home, had no fits or congestive attacks, no excitement or delusions. Weakness of mind GENERAL PARESIS IN WOMAN. I09 and bod}", onh', led to her admission : ph3'sicallv she was fairly well developed ; blank expression of face ; often nervous or frightened ; she would laugh or cr}" on slight provocation ; memor}^ much impaired ; no grandiose delu- sions ; gait unstead}^, tongue and lips tremulous, speech slurred ; pupils slightly dilated, the left larger than right, both irregular and reacting slowly to light, occasional nystagmus ; knee-jerk exaggerated ; had not menstru- ated ; chest rachitic, teeth syphilitic: angles of mouth puckered as if from old ulceration. She became weaker in body, muscular tremulousness and incoordination in- creased, had to be kept in bed. Mental dissolution also advanced steadily, resulting in almost complete dementia. There was no outstanding event during the illness. Died less than six months after admission, the disease having taken five and a half years to run its course. (Abstract, Middlemass, loc. cit., p. 38.) A CASE OF GENERAL PARESIS IN THE PRODROMAL STAGE IN WOMAN TREATED FOR MALARIA. A strong, health}^ lady ; forced to support herself be- cause her husband had died four years before of epilepsy. She became an attendant in a public institution ; after two years had to give it up, due to diminishing physical strength and mental indisposition or irritability. Went to New York city and was there treated for malaria. She complained of a feeling of weariness and lameness after walking. Her conversation did not indicate mental dis- ease, but investigation showed that attention, concentra- tion, memory and readiness of perception were impaired. There was deliberateness of speech and slowness of physical and mental action. She died four years after- wards in an asylum, a paretic. (x\bstract, Folsom, loc. cit., p. 8.) Senile General Paresis. — See section on age under etiology. CHAPTER IX. PARTICULAR SYMPTOMATOLOGY. Moral Perversion. — One of the most definite of the prodromal symptoms and sometimes the one first noted, is that of moral perversion. It is a result of mental disintegration, and may occur years before a marked outbreak of the disease. In other cases " simultaneously with memor}^, will and emotional unbalance the morals begin to totter." Here the symptoms are so obvious that a short time suffices to convince the most incredulous that disease is at work. The patient forgets business engagements, social proprieties, and moral obligations, and he is entirely ob- livious of responsibility in any one of them. Positive misdoing rapidly develops ; he uses improper language, mistreats wife and family, and indulges in excesses of all sorts. All of these tend to hasten the disease. At necessary remonstrance he creates a disturbance, perhaps uses violence, and is soon adjudged insane. But in a majority of cases the onset is much more gradual ; little by little the character and language change. The moral lapse seems at first a fault of memory, a thoughtless appropriation of trifling arti- cles, that naturally he would not desire, and, perhaps, a seemingly unconscious error of propriety. But a little later he steals in the most open way — anything and perhaps gives it away at once. These persons are most unconcerned when caught thieving and at once give a reason for their conduct. Often the aflTections change, and the sense of moral responsibility is wholly lost. This is always con- no MORAL PERVERSION. Ill nected with the progressive advance of the mental weakness. It has been pointed out that these moral lapses differ materially from the overt acts of those afflicted with so-called moral insanity. In the latter, as the result of a perverted moral sense and defective inhibitory action the instinctive impulses gain ascendency. On the other hand it is shown that in the paretic the deficient moral tone is due to a clouded intellect, the result of incipient dementia. This is quite apparent if we analyze the act, not only in respect to its motive, which is not impulsive but casual, but also in the mode of its accomplishment, which is devoid of forethought and judgment. AN ACT OF ARSON IN A PARETIC. S. B., set. 40, laborer, single, tried for burning a stack of straw. Fourteen years before he had severe head in- jury from a piece of falling coal. (Abstract, Baker, J. Journal of Mental Science, Vol. 35, p. 50.) INDECENT EXPOSURE IN A PARETIC. A professional man, who was arrested for indecent ex- posure and fined by the court, retired from the court room and repeated the offense. (Abstract, Stearns, Mental Dis- eases, p. 478.) A STUPID THEFT BY A PARETIC. A patient under my care broke into a shop window, ab- stracted a handful of cigars, and then sat down on the curb- stone to enjoy them, when he had sufficient money about him to supply his needs. (Abstract, Berkley, Mental Dis- eases, p. 174.) REPEATED PILFERING ; MARRIED A MULATTO. A patient, at an early period in his disease, would pick up small articles from store counters and put them in his pockets, and would not miss them when others removed 112 PARTICULAR SYMPTOMATOLOGY. them. He always strongly affirmed that he had bought articles, or that they had been given to him years before. This patient, a physician, had married a mulatto woman two or three years before his friends had him placed under legal restraint. (Abstract, Stearns, of. cit., p. 472.) DISHONEST TRANSACTION OF A RAILROAD OFFICIAL WHO PROVED TO BE A PARETIC. A railroad official, well known for his thrift and busi- ness ability, with no previous mental symptoms, went to a small town in western Virginia, where he was known. He took a room at the principal hotel, purchased several properties, and told his friends that a railroad was to run through the place, and that he had bought the properties so as to forestall the projectors of the road, as they wished to locate their depots and offices on these sites. He was so well known for his business acumen that a syndicate was formed by the local people, and the land rebought at an advance of thirty thousand dollars. The man left the town with his gains, which he dissipated within a few days. (Abstract, Berkley, op. cit., p. 173.) THIEVING BY PATIENT EIGHT YEARS BEFORE ONSET OF DISEASE. An old government officer, for eight years prior to his reception in an asylum, had been guilty of repeated abstractions of articles at public sales which he attended officially. After the last theft he was arrested. His phy- sician at once saw that he was mentally affected ; pronun- ciation embarrassed, face "petrified," walk heavy; when asked as to the circumstances of his arrest, the patient answered without remorse or shame: "The people who put me in prison are imbeciles, who know nothing of our professional usages. There is a custom among us, known as the ' cote G,' to choose some object of slight value and retain it when taking the inventory." And with this he took from his pockets a meerschaum pipe and a gold- mounted tobacco pouch. He was pronounced a paretic. SEXUAL INSTINCT. II3 and died a few months later. (Bierre de Boismont, vide Spitzka on Insanity, p. 187.) A PARETIC FISHERMAN ARRESTED FOR THEFT. A fisherman, who had presented signs of paretic de- mentia for six months, as it was subsequently ascertained, was detected emptying the nets of others and appropriat- ing their contents. He was first beaten by the owners and then taken before the court. Here he declared that his oars had become entangled in the nets and that he had taken the fish out in order to rearrange the nets, intending to replace the former. This explanation was rejected as a " cunning evasion," and a physician pronounced him of sound mind, although suspicions that he was insane were suggested by witnesses. The prisoner also announced the project of running a net across the Elbe river to be dragged by two steamers, thus catching all the fish at one swoop. (Simon, x'/tfig Spitzka on Insanity, p. 188.) Sexual Instinct. — In general paresis there is an insane exaltation of the sexual nature in many cases. The sexual power may be weak but the passion very strong. The female betrays much personal vanity and self-consciousness in the presence of men; she is often engaged in matrimonial designs. Frequently, the male patient suffers from the delusion that his wife is unfaithful to him, while he may run into vile excesses himself. LOSS OF SEXUAL ABILITY IN PARESIS. Loss of sexual ability in one case was among the ear- liest indications of the disease. (Abstract, Stearns, Men- tal Diseases, p. 472.) LOSS OF SEXUAL ABILITY AS AN EARLY SYMPTOM. In a case of the writer's experience, the wife mentioned loss of sexual power as an early symptom in the husband, although the desire was stronger than normal. 114 PARTICULAR SYMPTOMATOLOGY. PERVERSION OF SEXUAL INSTINCT IN PARESIS. Another case, which was in the second stage, displayed little or no natural sexual desire, but at the same time, shamelessly masturbated in the presence of his wife, to whom he was devotedly attached. Hallucinations. — Hallucinations of the special senses occur in about half the cases of general paresis. Visual and auditory hallucinations are the most com- mon and according to Mickle are found in forty per cent, of the cases; next in order, are tactile, gustatory and olfactory hallucinations, which are present in about twelve per cent. Hallucination of all of the special senses is sometimes found in the advanced stages, the patient showing visual, auditory, olfactory, gustatory and tactile perversion, the result of the ad- vancing degeneration of the neurons of the cortex. The hallucinations of paretics are usually variable, unstable and inconsistent, being less systematized than those of many other forms of insanity. Spitzka com- pares them with those found in some of the acute in- sanities, such as in alcoholic insanity and contrasts them with those of paranoia, where they are fixed and systematized. Hallucinations, illusions and de- lusions are liable to be combined in varying degree, and it is troublesome, if not occasionally impossible in practice, to separate the long catalogue of these perversions into their respective category. Again, prominent delusions may mask the less conspicuous manifestations of the other morbid perversions, and to this fact may be attributed the paucity of hallu- cinations among paretics that is found in the experi- ence of some observers. Visceral sense-impressions, scarcely noticed in normal conditions, are vivid in the paretic and be- come linked with his delusions. Especially is this HALLUCINATIONS. II5 the case in the hypochondriacal form when, visceral sense-impressions (illusions) are a marked feature of the perversion. Joyful hallucinations accompany the ambitious deliria, while painful ones pursue those afflicted with melancholic depression. In one case, countless frogs were seen by the patient hopping about him, whose intestines bulging out from the vent, had been stuifed into their mouths; another patient heard voices commanding him to kill some one, in order that he might himself be compelled to commit suicide (Spitzka). Some writers hold that the sense of pain, expressed in groans and cries in the last stage of the malady, is not hallucinatory, but is due to nervous lesions, either central or peripheral, and that the assurance in per- sonal strength, frequently so confidently expressed in the first and second stages, is not a delusion, but more properly an hallucination, due to the morbid perver- sion of the kinesthetic sense. The question is sometimes asked whether hallu- cinations are met with more frequently in the expan- sive, or in the depressive form of the disease. It seems to be a very general experience that they are oftener found in the latter cases, or it may be, owing to the distressing nature of these hallucinations that they are forced more readily on the attention. Camp- bell Clark gives a striking example of the uncanny nature of these hallucinations in the depressant form. The patient declared that he had seen in the night his house filled with black dogs, and the noise of their howling kept him awake all night. He had the hallucination, also, that a drowned man was touching him; said that his saliva tasted very bitter and that it was poisoned; that laudanum had been given him; and the doctor had opened him in his sleep; and that he had been blistered with two fly blisters. CHAPTER X. PARTICULAR SYMPTOMATOLOGY i^C07ltinued^, Facial Expression. — The face of the paretic presents a characteristic lack of expression. The tense facial muscles, which give expression to the individual face by the special lines and wrinkles which the}- cause, be- come enervated, and no longer respond to the quick play of feeling, which may, or may not, still exist in the mind. In either case the expression is compara- tively characterless. The face takes on a putfy, apa- thetic appearance, somewhat resembling the cast of the drunkard, with which it has been compared. This expressionless, mask-like look has been termed " the petrified face." While the patient is uninterested or the features are in repose, the expression is peculiarly blank and stolid, but when animated there is a complexity of expression difficult to describe. There comes a tardy and usually but a partial response to the facial mus- cles; the face may beam with excitement, the eyes staring and the mouth smiling, and at the same time the lips and facial muscles become tremulous, so that the expression is a mingled one of pleasure, pain and surprise, which only interest or excitement prompts. Frequently, because of the irregularities of inner- vation, one part of the face expresses one emotion, while another part expresses a different one, and, as has been said, it " reminds one of a badly executed portrait, in which the features do not harmonize in their expression" (Sankey). ii6 SPEECH. 117 Some parts of the face are more continually in action than other parts and they show first the lack of control. The mouth loses its firmness, and the lower part of the face becomes smooth and heavy; the naso-labial lines disappear, leaving a puff}- and sometimes pouting look about the mouth, and almost always there is added a tremulousness of the lips. Sometimes there is a sleepy look about the eyes, and a relaxing, which may amount to a paresis, of the muscles of the upper part of the face, causing a drooping of the eyebrows. The eyelids sink, and a vacant expression is the result. But, again, there may be a muscular twitching about the eyebrows, and a muscular tension about the forehead, which tends to keep the eyes very wide open and to pro- duce an unusual expression of unfelt astonishment. Often the forehead is corrugated and remains so to the end. Towards the last the facial aspect is dull, glassy and vacant, giving no sign of emotion, except- ing, now and then, a furtive glance of amazement, or of fright. Speech. — The speech early betrays the existence of general paresis. This, the highest expression of men- tal life, the most delicate of motor-coordinations in the well-modulated voice and clearly-enunciated words, the last accomplishment to be acquired, is the first to fail. The complications necessary to a communica- tion of ideas must necessarily be touched on every side by the beginning of this disease. The formerly clear mind is troubled by a sense of confusion, an in- ability to command immediate control of the mental processes ; this is followed by intellectual weakness and by impairment of memory and of attention. At the same time a slight hesitancy in speech, together with a trembling or slight stiffening of the upper lip, early I 1 8 PARTICULAR SYMPTOMATOLOGY. shows a disordered relation between ideation and the coordination of the vocal organs. The peculiarity of speech is difficult to describe, for there are always slight individual differences, but it is so characteristic that heard a few times it is readily recognized. Under the three stages of the established disease will be found a detailed description of the paretic speech. It is not unusual to find aphasia associated with paresis, as the following cases illustrate: THREE CASES OF GENERAL PARESIS EXHIBITING APHASIA. 1. A paretic, when received, was unable to express him- self intelligently ; he understood what was said to him, and could repeat words spoken to him without difficulty. Motion on right side was more impaired than on left. Subsequently, an epileptiform attack left total right hemi- plegia and complete aphasia continuing until death, nine months later. 2. A paretic, had aphasia on admission, being complete word deafness, which came on after an apoplectic attack ; a vear previously, there had been transient right hemiplegia, after which he only uttered a few unintelligible sounds ; he understood nothing of what was said to him and ex- pressed himself by gestures. Death from edema of lungs. 3. The patient's illness was attributed to a severe blow on the head, followed later by an apoplectic seizure, leav- ing right hemiplegia and aphasia. When received under treatment, there was paralysis with contracture of the right extremities, general muscular weakness, and apparent inability to understand what was said ; he died from pneu- monia. (Abstract, Rosenthal, American Journal of In- sanity, Vol. 46, p. 398.) APHASIA AS AN EARLY PRODROMAL SYMPTOM. The wife of patient noticed temporary loss of speech, followed by hesitation and tremor nearly eight years before serious disease was suspected. The attacks of aphasia recurred at intervals and when it became necessary Plate VIII. Round the rugged rocks the ragged rascal ran. Specimens of the Handwriting in General Paresis. These are facsimiles of the handwriting of three paretics, all of whom were in an advanced stage of the disease. In the last case the patient was found to be too much demented to complete the alliterative lines, so he was then given the easier task of writing the shorter sentence. Observe in the first instance that he started to sign his name when he had finished the first word of the sentence ; he was persuaded, how- ever, to continue with the copy, with what ill success may be seen, after the abortive attempt to write Edward, his christian name. HANDWRITING. II 9 to send the patient to an asylum, the difficuhy of speech and tremor of tongue and lips were well marked. (Abstract, Savage, of. cit., p. 286.) Handwriting. — The handwriting of paretics is of importance, as it early shows tremor fin the wavy up- or down-strokes. This tremor of itself will not decide the case, for tremor may occur with age, alco- holism or in diiferent nervous defects, and specimens of handwriting from all are similar; but the general paretic shows an inability to control the attention for any length of time, and with the effort comes an in- creasing weakness of understanding and memory. In the first stages the patient may write a fairly steady hand, but there is a lack of carefulness in the finer movements; final letters are often omitted; lapses of words, reduction of double consonants, rep- etitions of words or even of sentences, reduplication of letters or syllables all tell the story of unusual effort required to write clearly. Early in the disease the patient may notice his failure to write rapidly and by writing slowly may cause a decided improvement, but as the disease advances he loses this power of control. The handwriting degenerates to a scrawl, and the deviations from straight lines become more apparent. In lengthy documents the beginning may be fair, but as the patient tires a little, the formation of words grows more irregular. It becomes impos- sible for him to follow the line; he writes above or below it but usually runs obliquely down across the page. The omission of words happens more fre- quently, and a meaningless repetition of even whole sentences may occur. The serious mental condition is apparent in these efforts, as well as the lack of muscle control; the ideas are confused and the sentence seems to fade I20 PARTICULAR SYMPTOMATOLOGY. from the mind before the patient can put it on the paper. Many patients show an inclination to deal with financial affairs, and their scrawling letters con- tain orders for expensive jewelry, famous pictures or checks for fabulous sums. As the disease advances, the writing becomes more and more illegible, and when the patient is unable to make himself understood in speech, he can no longer write. Gait. — In the first stage of the disease one unac- quainted with the patient might fail to notice anything peculiar in his walk, but to the trained eye, or to an acquaintance, a stiffness of gait is readily apparent; it may seem only an unusual dignity of bearing, but there is an absence of elasticity, the feet are not raised as much as usual, the steps are shorter and quicker, the heels are set down with more force, and the body is held in such a way as to give an observer the idea that the head must be balanced with care. The patient will find dithculty in stepping up into a chair; he may walk well on even ground or on a tioor, but stumbles in walking on uneven or unfamiliar ground, or if it be necessar}^ to step over any obstruction, even though seen perfectly. Quick movements, like dancing, are impossible. Going up and down stairs is troublesome; the whole foot must be rested securely on each step and a careful poise of the body must be maintained. This impairment in coordination may be noticeable some time before any mental symptoms appear. In the second stage of the disease the impairment in gait is very obvious; even the station is affected, for the patient never shifts the weight of the body from one foot, nor does he move in an easy, careless manner, but instead keeps the body firmly poised on both feet, and in walking, often inclined to walk Plate IX. i ? <3 c? ^ ■'i t, ^ z:^ ' haustion, with muttering delirium, and picking at the bed- clothes. During the next week, he failed rapidly. The arteriosclerosis increased. His pulse ran up to 120. He occasionally had an involuntary stool and passed his urine in bed. He thought his room was haunted by dogs and cats but he was generally in ecstasy. Three days before death he became stuporose and the day before he died he had right hemiplegia, without involvement of the facial muscles. (Abstract, Tomlinson, Journal of Nervous and Mental Diseases, Vol. 16, p. 772.) Race and Social Influences. — So free are some coun- tries from general paresis that for a time it was sup- posed to be confined to certain races, particularly to the Anglo-Saxon. This was based on the fact which now is well determined that it is unknown in Asia and to the savage in his native state. The disease accompanies the hurry and worry of the extreme struggle for both existence and high place in late civilized life, regardless of race or nation. For example, the Scotch Highlander is free so long as he remains in his rural surroundings, with little to fire his ambition or imagination, but when he goes into city life and his energy and determination are bent on competition, he places himself in a position that may readily end in his being a paretic. The Irishman, too, almost entirely free from the disease at home, is not at all exempt from it in American cities, or in English factories and mines, where in the latter case, his life is made up of the hardest of work and the lowest and roughest of surroundings. It is said the disease was unknown among the slaves of the Southern States and unreported among free negroes until they came to the centers of popu- lation. At present in Baltimore, as an instance, pare- sis claims the same percentage of negroes, according 2IO ETIOLOGY. to the population, that it does among Caucasians. In Norway and Sweden the disease is ver}^ rare. In France and Germany it is common among brain work- ers. In our own country and in England it is found most frequentl}' in regions where competition has been strongest for several generations. In the Western States onl}^ one or two per cent, or less, are general paretics when coming from farm life; but in the East- ern States from ten to sixteen per cent, in the populous districts. Berkley ^ says : " It is in the cities where rum and S3philis dwell in close fellowship, where the strife and excitement of modern civilization is ever at flood tide, that general paresis is rife." Spitzka,^ from a careful study of the subject among the indigent insane of New York City, gives the pro- portion of general paretics as follows: Anglo-Saxon, 13.29; Celts, 11.58; Germans, 11. 13; Hebrews, 10.29; Negroes, 8.82. He shows that the Anglo-Saxon race, the one of greatest speculative business tend- encies and of highest intellectual development, has the largest number; that mere business exertion is not the most fertile cause from the low percentage of the Hebrew race; that intellectual exertion, per se, is not a cause, as shown by the lesser percentage of the Germans, who stand first in the abstract and specu- lative sciences; that a libidinous life is not wholly re- sponsible, for if such a reflection were to be cast on any race in this respect it would be the Negro race, which shows the lowest percentage of general pare- sis, and to which, living in natural conditions, not compelled to enter into competition, the disease is unknown. The writer then adds: "The conclusion will seem reasonable that general paresis is more fre- quent with races of a high than of a low cerebral or- ' Mental Diseases, p. 194. 2 Manual of Insanity, p. iSi. PUte X. GENERAL PARESIS IN THE NEGRO. RACE AND SOCIAL INFLUENCES. 211 ganization, because their higher civilization induces a restless mental activity and its attendant emotional strain. General paresis, therefore, is not a penalty of high cerebral development, but the expression of a discrepancy between the instrument and its pur- pose; of the inadequacy of some brains to support the strain to which the race, as a whole, is subjected." It is generally agreed among alienists that the gen- eral conditions incident to the life of the poor predis- pose them to insanity, and it is found that a higher per cent, of these classes become insane than those of the middle and higher classes. Whether this rule applies to the distribution of general paresis is a mooted question. Some authorities, as Mickle, be- lieve that paresis is more prevalent in the lower classes, while other observers of equal rank, for in- stance Regis, find that the upper classes suffer most from it. It appears from compiled statistics of the insane, for a series of recent years, comprising the in- sane of the Atlantic seaboard in and about the large commercial centers of Boston, New York, Philadel- phia and Baltimore that the highest per cent, of gen- eral paresis among men makes its appearance in the better classes of societ}^ Of 17,633 indigent male patients, 13.7 per cent, were general paretics, and of 16,956 indigent female patients, 1.3 were general paretics; of 3,005 private male patients the percent, of general paretics was 16.2, and of 2,736 private female patients the per cent, was .18. The result, therefore, may be put down in the following order: (i) Men of the upper classes, (2) men of the lower classes, (3) women of the lower classes, (4) women of the upper classes. This proportion holds good equally for the local divisions in and about the four large cities mentioned, excepting in the case of Phila- delphia; here among the women the larger per cent. 212 ETIOLOGY. was with those of the higher classes. There is no ex- planation to offer for this variation from the general rule. Whatever ma}' be the truth in respect to the general rule, one fact is assured — the disease is on the increase. The restless pursuit of wealth and social position, the anxiety and hurry, emotional strain and intellectual overwork, the unhygienic modes of life and especially of the laboring class, the excesses in excite- ment and excitants together with syphilis, tend to fix on modern civilization a most deadly foe, unknown in former times. PARESIS IN A MULATTO WHO HAD BEEN FORMERLY A SLAVE. G. R., a mulatto, male, age 22, of large stature, and fine athletic appearance, admitted July 5, 1855. He was a native of Maryland and had been a slave. His insanity was ascribed to excitement at a religious meeting. On admission he was tranquil and very docile, but was sub- ject to short and very violent paroxysms, in which he was dangerously furious. His bowels were usually constipated before these attacks. He complained of want of feeling in his feet and the anterior surface of his legs. He had a great desire for education and often wept because he could not read. Once he escaped from the asylum grounds but was brought back and on the twenty-third day after admis- sion killed himself by jumping from the asylum roof. (Abstract, Workman, American Journal of Insanity, Vol. 13, p. 22.) Excesses. — Alcoholic and sexual excesses, indulged singl}' or combined, are especially potent causes of the disease. With the excessive use of alcohol the effect in some cases is direct, and the most conservative of writers say that it is prolific in its tendency when intellectual or emotional strain exists. " A mere physiological hyperemia of the brain, under the use EXCESSES. 213 of alcohol, may become pathological and determine the onset of paresis" (Dercum). In a table prepared by Mickle from Reports of the Commissioners in Lunacy (England), by far the highest percentage (21.4) was attributed to intemper- ance in drink. Some other statistics give as high as thirty per cent. Of sexual excess, there has been some confusion as to the excess producing the disease and the excess which is a common early symptom of the disease. It is an early symptom in some cases, as are many of the irregularities of the life in the early stages of the malady, but usually this as a symptom continues only a short time, while, if the facts can be secured in very many cases, a history of earlier excesses will be found. It is recognized as an exhausting cause and in conjunction with prolonged anxiety, or exces- sive emotional strain, or even exhausting physical work, it tends to bring about the conditions of the disease. Savage sums up his researches thus : " Gen- eral paresis usually arises from a combination of causes, the most common direct cause being excesses of all kinds, whether sexual or alcoholic, which act more powerfully when associated with strain, worry and anxiety." GENERAL PARESIS IN WHICH EXCITEMENT AND EXCESSES PLAY A PROMINENT PART. A case of this nature presented expansive ideas and pro- jects, great restlessness and some excitement with moral defect, the physical symptoms being obscure. After three months an abatement of the conditions occurred, so that some of his friends insisted that a mistake had been made in diagnosis and he was set at liberty. But he soon plunged into a life of speculation, became indecent in lan- guage and lascivious in conduct, and died in less than 214 ETIOLOGY. three years of general paresis. (Abstract, Stearns, o-p. ci'L, p. 509.) A CASE OF GENERAL PARESIS, THE RESULT OF INTEM- PERATE PARENTS. A boy, cSt. 16, showed progressive paralysis, with com- plete fatuity and great emaciation, also contractures. He was in a very demented state a year before death. Father was English, mother Italian ; both very intemperate. Par- ental neglect and semi-starvation were prominent features in the case. (Abstract, Wiglesworth, Journal of Mental Science, Vol. 39, p. 367.) Toxic Agents. — Aside from the toxin of syphilis, that takes so important a role, as a causative factor in the disease, there has been of late years a tendency among man}^ of the best neuro-pathologists to accept the theory, which was first put forth by Angiolla, that general paresis is a toxic atiectioii produced by auto-intoxication, either directly or indirectly, through an interference with nutrition. It is in this malign way that lead (Kierman et a/.) and tobacco (Guis- lain ef aJ.) are supposed to act in the few cases that now and then are ascribed to these agencies as the ex- citing cause. According to these observers the bane- ful influence of alcoholic a'buse and licentiousness, as well as mental overstrain, is to be sought also in these nutritional defects that contaminate the blood with poisonous products, which induce the degener- ative changes in the nervous tissues. Injury to the Head. — Trauma of the head is recog- nized as a cause of general paresis. In the four thou- sand two hundred and eight3--four cases collected by jNIickle two hundred and eighty were attributed to such injury. Probably a large number of the cases with little mental derangement, found for the most part in general hospitals, are those which result from this cause. INJURY TO THE HEAD. 215 Dercum-^ gives this theory in explanation: "Con- cussion of the brain seems to lessen its power of resistance, perhaps affects directly the vaso-motor control of its larger vessels and thus predisposes it more readily to attacks of congestion. It is very probable that sunstroke acts very much as does con- cussion of the brain, namely by predisposing the organ to hyperemia and by lessening its power of resistance." In ninety-seven of the above cases given by Mickle, sunstroke was the assigned cause. In cases of trauma paresis may follow at once, but more frequently, it is years before the disease appears and then it is a gradual development. GENERAL PARESIS FROM INJURY TO THE HEAD. One was a man in the dock yards, the other a butler. Both immediately developed general paresis. A predis- position already existed, the blow being an exciting cause. (Abstract, Rayner, Journal of Mental Science, Vol. 37, p. 488.) A CASE OF GENERAL PARESIS FROM A BLOW ON THE HEAD. An engine-driver at the Hullborough Asylum six years before admission had a fall on the back of his head ; he had not been the " same man " afterward. He became irritable, especially with his children ; threw knives at them and tried to stick needles into their eyes. When he came to the asylum he was unsteady in his walk, which he attributed to " a stroke." Fifteen months afterwards he was far advanced in general paresis ; his gait was bad ; his articu- lation drawling; pupils unequal. He said he was "all right," but thought that some one had taken him out of bed during the night and set fire to it. (Abstract, Bucknill & Tuke, Psych. Med., p. 313.) * Nervous Diseases, p. 670. 2l6 ETIOLOGY. A CASE OF GENERAL PARESIS RESULTING FROM FALL ON HEAD. C. H., set. 56 ; fall on vertex some time before admission ; insane immediately on receipt of injury, lasting four weeks with maniacal excitement. Present attack six months pre- vious to admission. He was intemperate ; pupils irreg- ular ; he showed ataxic articulation and expansive ideas, and general tremor with characteristic physical condition ; apoplectic seizures seven months after admission ; death from exhaustion fifteen months from onset of disease. (Abstract, Neff, American Journal of Insanity, Vol. 53, p. 41.) A CASE DUE TO INJURY OF HEAD. L. T., 53, moderate drinker, injury to head four months before development of disease : unconsciousness for a few hours ; acute delirium for ten days. Immediately after- wards mental confusion, loss of memory, mental enfeeble- ment, apprehension, expansive ideas, ataxic gait, occipital headache, paresis of arms and legs, aphasic and hesitating speech ; he had a fair realization of his condition ; psychical symptoms increased. One month after admission, he had general clonic convulsions, terminating in paresis affecting arms and legs. Respiration embarrassed ; patient died of asphyxia. (Abstract, Neff, /oc. ciL, p. 41.) INJURY TO HEAD THE PREDISPOSING CAUSE OF GENERAL PARESIS. A man who had an injury to his head, became insen- sible, recovered and remained well for two years before symptoms of paresis set in. (Abstract, Mickle, ride Sankey.) PARESIS FOLLOWING INJURY TO HEAD OF LONG STANDING. The history of a case of general paresis showed that the patient had had an injury to his head many years before, and he bore the marks of cicatrices. (Abstract, Sankey, 0^. ci'L, p. 287.) INJURY TO THE HEAD. 217 GENERAL PARESIS CAUSED BY THE FIRING OF A LARGE GUN. A case of paresis was caused by the firing of a twenty- five-ton gun close to which he was standing. He had ex- alted delusions on admission, declaring that when he shook his fingers, gold dropped from them. After becoming quieter, more rational and his memory having improved, he fell into a state resembling catalepsy. About 6 A. M. of each day, he would pass into a condition of perfect stillness, lying flat on his back, not moving a muscle ; this con- tinued until 3 A. M. the following morning, when he gave signs of life by speaking to the attendant and swallowing food placed into his mouth. At 6 A. M. when the stage of stillness was coming on, he would perspire profusely, this gradually diminishing as the day wore on. His morning and evening temperature rose during this period and once or twace slight twitches were observed. He w^as apparently quite unconscious, pupils sluggish, sensation and motion suspended. When this periodic condition finally passed off after a month's duration, he was comparatively rational and had lost his more prominent delusions. Four months after, these delusions returned and the disease steadily pro- gressed. On awakening to consciousness in the morning he was evidently under the influence of hallucinations of hearing. (Abstract, Bucknill & Tuke, op, cit., p. 315.) CASES OF PARESIS FOLLOWING DEAFNESS, MOTOR NERVE ATROPHY AND TRAUMATISM OF BRAIN. (i) G. B. A. became stone deaf in one ear several years before he developed general paralysis. Clouston believed the case was one of propagation, though he had no patho- logical proof of it. The patient was a medical man and thought that the symptoms of general paralysis which fol- lowed were due to the extension of the disease of his in- ternal ear into the brain. (2) Professor Laycock used to quote a case of his where the disease had spread upwards from a Wallerian atrophy of one of the motor nerves of one of the fingers. (3) G. D., a woman of 36, passed gradu- 2 1 8 ETIOLOGY. ally into quiet non-delusional general paralysis after a small punctured wound due to a pitch-fork in the top of her head, penetrating for about an inch into the brain. After death, all the convolutions of the cortex were affected, especially around the wound. (Abstract, Clouston, Mental Diseases, p. 390.) Epilepsy. — Epileps}' is not a common predisposing cause of paresis, but its action on the brain, inducing intense cerebral congestion, does undoubtedly result in paresis at times, and the clinician should be aware of this occasional mode of development. Epilepsy which may be the cause of paresis, must not be confounded with the epileptiform attacks which are episodic in nature. Mendel gives two cases of paresis, one of a man of thirty-five, who had been epileptic from fourteen to twenty 3' ears of age, and the other of twentj^-eight years of age, who had been epileptic from his eighth to his thirteenth 3'ear. GENERAL PARESIS IN AN EPILEPTIC. A commercial employe, 33, had been an epileptic. He lost his wife soon after marriage, causing him deep grief. He died of paresis in asylum three years after admission. He did not have an epileptiform attack in the asylum. (Abstract, Christian, American Journal of Insanity, Vol. 44, p. 498.) GENERAL PARESIS DEVELOPING IN AN EPILEPTIC. J. N., male, ast. 32; native of Ireland; inmate of the asylum for nearly five years ; had been formerly epileptic, but not so latterly. His head was very large and, phren- ologically, well formed. He was very quiet and childish ; his general health feeble. Three weeks before death he complained of pain in various parts of his body and was confined to bed. On the day before his death, he had a fit of syncope, from which he soon rallied but showed Plate ^ GENERAL PARESIS FOLLOWING EPILEPSY. This patient had been an epileptic for twenty years before the symptoms ot general paresis developed. EPILEPSY. 219 difficulty in breathing and depression. A few hours after he complained of pain in the lower part of his chest and died on the following morning. (Abstract, Workman, loc. cit., Vol. 13, p. 18.) GENERAL PARESIS IN WOMAN. HISTORY OF EPILEPSY. DURATION TWO AND A HALF YEARS. K. W., a mistress, set. 28, fair education, formerly a lady's maid. Admitted in August. She had been sub- ject to epilepsy from the age of 9 to 12 ; father and uncle epileptic, and died imbecile; " on the fits leaving her she became altered in disposition," probably at puberty. She was always of a haughty, ambitious character ; left service and was kept in luxury by a gentleman for some years ; afterwards was left for six months, but still supplied with means ; supposed to have become addicted to drink, became invalided and for a time was ill, nature of illness uncer- tain, had to part with all her goods ; was maintained by her female companions ; drank more and was at times muddled for a whole week together. Gradually became affected in mind, excited at times, talked to herself, when addressed would not reply, restless, would dress and undress repeat- edly during the day, slovenly in her person, was taken to workhouse, where she was described as indecent in behavior, frequently exposing herself, talking to imagi- nary people, restless, said she had large property. On admission to asylum, not noisy, restless, answers questions in a whisper, talks to herself. Slept well, expression of vacancy and confusion, frowns and knits her brows, pupils equal and act well, does not know how long she has been in the asylum (came yesterday) ; cannot tell the day of the week, has no headache, very untidy in dress, tongue tremulous and clean, bowels not open since admission, no chest symptoms. Nothing peculiar in gait, pulse 80, she is pale, in fair bodily condition. First month, right pupil large ; she is occasionally violent ; walks with firm step. Second month, good bodily health, pupils un- equal ; she cannot understand what is said, right ear swollen. Sixth month, drawling tone, violent at times 220 ETIOLOGY. and very noisy, walks well, but frequently falls as though her knees gave way. Ninth month, one morning she appeared to have lost use of left side, in afternoon walked with limp on left leg. Fifteenth month, more paralyzed, mind very imbecile, mutters unintelligibly, wet and dirty, swallows with difficulty, dejections passed unconsciously, sordes collected on teeth. Sixteenth month, pupil dilated ; she is unable to stand, rallied a little in mind, swallows rather better, conjunctiva injected, failed slowly to eighteenth month ; both pupils became contracted. Death by exhaustion. (Abstract, Sankey, of. at., p. 322.) Physical Ovenvork and Strain. — Exhausting physical labor is to a certain extent undoubtedly an exciting cause of general paresis, especially when not coun- teracted by pleasant diversion, or by intellectual ex- ercise. This is particularly true when acting upon those in whom the nervous system has lost the elas- ticity of youth and its ability to respond after fatigue. If the condition of the system has been impaired by the use of alcohol, it is then especially susceptible to the effects of steady overwork. It is not the work that kills; seldom, perhaps never, does this of itself end in general paresis; but the endless monotony, the subjection to extreme heat, sudden changes of heat and cold, tend to wear on and weaken the central nervous system, and when this condition is associated with ill-regulated passions, strain, poverty, anxiety, or extreme disappointment, the brain falls a ready prey to paresis. GENERAL PARESIS INDUCED BY EXPOSURE TO COLD. The patient, a man, reached home, having been out in the snow all night and from this time had violent pains in his limbs. Two years afterward, his pains ceased and then he began to show symptoms of paresis. (Abstract, Chris- tian, loc. cit.. Vol. 44, p. 496.) INTELLECTUAL OVERWORK. 221 Intellectual Overwork, Anxiety, Mental Shocks Etc. — Intellectual work done judiciously should never injure. Even neurasthenia claims a lower percent- age of professional and intellectual men than those of other occupations. But forced intellectual labor, carried on with imperfect training, creates anxiety and uneasiness, continually weighs down the spirits, disturbs the sleep, wears with special force on the brain, and readily predisposes to paresis. Again, the early training may have been thorough, but if one is obliged to work under keen emotional strain, or excessive anxiety, especially if fatal re- verses threaten, the constitution must be strong and the control over self sufficient, if one is to escape from the ill consequences of such conditions. Paresis is well said to be the disease of civilization — the disease of mental stress. It is the worry rather than the work that does the damage. Savage says: " General paralysis occurs mostly in the anxious- minded, conscientious man, and as far as my expe- rience among the middle classes is concerned, it is rather due to overstrain than to overwork." Excessive worry and anxiety in one case may in- duce mania or melancholia, while in another paresis. Stearns refers to a table of six hundred and thirty- four cases of paresis, of which one hundred and six were attributed to " largely reverses in fortune, grief, anxiety, and distress arising from unfortunate social relations." Of Mickle's table, fifteen per cent, were assigned to mental anxiety, adverse circumstances, worry and overwork. GENERAL PARESIS CAUSED BY MENTAL STRAIN, WORRY, AND ANXIETY. An energetic manager of a successful business prose- cuted some workmen under him for want of performance 19 222 ETIOLOGY. of their duties. He failed to get a conviction, which led to a conspiracy of the workmen, and the result was that his life was rendered miserable by a system of threatening and intimidation. Sleeplessness, worry and loss of appetite were followed by the ordinary symptoms of general pare- sis. (Abstract, Savage, of. cit., p. 284.) GENERAL PARESIS FOLLOWING MENTAL SHOCK. A man acquired general paresis who suddenl}'- found that his son had forged his name for a large amount. FOLLOWING MENTAL SHOCK. A widow lost her onl}"- child by a fever in a few days while traveling abroad. GENERAL PARESIS FOLLOWING GRIEF. A man returning from India, lost his wife during the voyage and a child directly after landing. FOLLOWING LOSS IN STOCK MARKET. A speculator in the stock exchange, on losing a very large amount of money, acquired general paresis. FOLLOWING GRIEF AND DISAPPOINTMENT. A widower, left with two sons, after carefully superin- tending their youth, found, on their coming of age, that they both threw off their allegiance and launched into extravagance and vice, one of them speedily drinking himself to death. The other began to follow the same course. The father acquired general paresis on the death of the eldest. (Abstract, Sankey, op. cit.^ p. 291.) GENERAL PARESIS FROM OVER-JOY. A hair-dresser's wife with a family of children had been in a state of destitution all winter. One morning her husband came home with the news that he had got permanent em- ployment and gave her a sovereign which had been ad- vanced to him. In the evening, he found that she had INTELLECTUAL OVERWORK. 223 spent the sovereign wholly in buying carpet-slippers which she said she meant to sell for a large sum. In this case the exciting cause was over-joy. (Abstract, Sankey, o^. cit., p. 291.) DISAPPOINTMENT THE EXCITING CAUSE IN A CASE OF PARESIS. A navy officer became engaged to the adopted daughter of a wealthy bachelor uncle who permitted the marriage on condition that the officer should give up his profession and live near him, he making them a handsome allowance. But the uncle married his nurse and changed his will so that, on his death, his niece was deprived of all her expec- tations and her husband developed general paresis. The actual catastrophy only acted as an exciting cause probably for the husband had amaurosis at the time. (Abstract, Sankey, o;p. cit., p. 290.) CHAPTER XVI. GENERAL PARESIS FOLLOWING ORDINARY INSANITY. General paresis seldom occurs in ordinary insan- ity, yet, as pointed out by Mickle, the operation of new agencies, or the aggravation of old ones, may light up general paresis in a chronic case of insanity. GENERAL PARESIS WITH PERIODS OF MANIACAL EXCITE- MENT ALONE FOR SEVERAL YEARS. G. G., set. 36. Irish, drunken and hard-working, mar- ried. He had an attack of " acute mania" in 1876, was sent to the asylum and "recovered" in five weeks. No evidences of general paralysis were noted. Again in 1878 he had a similar attack, but no diagnosis was made, al- though some suspicion of the disease was excited, and it was only after his third admission in 1879, ^^^^ ^^^^ disease was fully manifest. He died with it in 1882. His wife showed that he was weakened intellectually after his first attack. (Abstract, Clouston, Mental Diseases, p. 393.) GENERAL PARESIS WITH MANIACAL EXALTATION ALONE FOR MONTHS. G. H. was acutely maniacal, very dangerous, homicidal, impulsive, strong-willed and unmanageable for twelve months, before there were any motor s^'mptoms that en- abled Clouston to diagnose general paralysis. From the state of his pupils and the expression of his face, he sus- pected it, but he could not say definitely it was any other condition than acute mania for the first year. (Abstract, Clouston, op. cit., p. 394.) 224 PARESIS FOLLOWING ORDINARY INSANITY. 225 GENERAL PARESIS DEVELOPING IN AN IMBECILE. M. Christian relates a case of general paresis in a man who, born in 1824, was under treatment from 1855 to i860 by Calmeil as an imbecile. His friends assumed the care of him until 1878, when he again became disturbed, having delusions of persecution and manifesting marked mental enfeeblement. Cerebral congestions became frequent and general paresis appeared and followed a usual course. (Abstract, American Journal of Insanity, Vol. 37, p. 449.) DEVELOPMENTAL GENERAL PARESIS IN A CONGENITAL IMBECILE. Margaret C, first admission, ast. 17, had no relatives to tell her history, but was regarded as a case of congenital imbecility. She was said to have been insane for at least three years ; she was undersized, badly developed, with considerable mental enfeeblement. There was mild ex- altation ; when spoken to she usually smiled foolishly, said she felt fine, memory much impaired, no delusions, no motor symptoms. While in the asylum, she picked up a little, was slow in her movements, occasionally quarrel- some, liable to fits of rage or slight excitement, but gen- erally happy. After sixteen months, she was transferred to lunatic wards of poorhouse and then boarded out in the country. Readmitted to asylum three years after dis- charge. During this time, almost nothing could be learned of her condition. She remained fairly quiet and manage- able, but mental enfeeblement had steadily progressed ; she became very weak in body, could not stand, some paresis of right side and considerable difficulty in swallowing. Her mind was almost a complete blank ; she seldom spoke, voice monotonous and tremulous, lips and hands tremulous. The disease had reached a very advanced stage. She died ten days after admission of pneumonia in a phthisical lung. The case was not thought to be general paresis until post- mortem. (Abstract, Middlemass, Journal of Mental Science, Vol. 40, p. 37.) 2 26 PARESIS FOLLOWING ORDINARY INSANITY. A CASE OF GENERAL PARESIS RAPIDLY FATAL. THE PATIENT HAD RECOVERED FROM AN ATTACK OF INSANITY SEVEN YEARS BEFORE. E. G., married, ret. 33 ; grandfather melancholy, parents healthy. The supposed cause of this attack was anxiety about money matters. There was a history of a previous attack of insanity, seven years before, with complete re- covery. This attack began with hesitation in speech, great incoherence, sleeplessness, and refusal to take food. He fancied his shop assistants were being starved, and that people were removing goods without payment. He was found on admission to be weak, nervous and restlessly ex- citable. In three months, he was very feeble on his legs and hard to understand due to thick speech. Later he had a convulsive fit, from which he recovered, but remained in a half dazed condition-. There was no special paralysis but great exaggeration in reflexes four months after admis- sion. He was found one morning, unconscious, head turned to right, conjugate deviation of the eyeballs to right ; pulse 170, respiration 55, temperature 105°; right pupil slightly larger than left ; loss of power of rectum and bladder ; Cheyne-Stokes breathing ; he sank into deep unconscious- ness and died. (Abstract, Savage, o^. cit., p. 296.) GENERAL PARESIS PRECEDED BY ACUTE MANIA IN YOUTH. G. H. A. had an attack of mania in youth, recovered, kept well, and performed his ordinary business, and at the age of 44 became a general paralytic. (Abstract, Clous- ton, op. cit., p. 395.) HYSTERICAL INSANITY FOLLOWED BY GENERAL PARESIS. Woman, 33, an ordinarily violent, maniacal patient, somewhat hysterical ; duration of insanity given as two years. The symptoms commenced by hysterical crying and agitation. Only motor signs, exaggerated reflexes and hysterical shaking ; she gradually quieted down ; paretic symptoms some months later, were typical during her decline and death ; she died after one year and ten PARESIS FOLLOWING ORDINARY INSANITY. 227 months. (Abstract, Phelps, American Journal of Insanity, Vol. 53, p. 59.) GENERAL PARESIS SUPERVENING ON CHRONIC MANIA OF LONG DURATION. Jane M., ast. 40, Irish, occupation, domestic ; duration of insanity, many years ; diagnosis, chronic mania. History on admission, she had delusions of poison, and had haunted the Supreme Court for years, thinking she had a suit there. She improved physically, mentally she re- mained the same ; she was removed to almshouse. Read- mitted to asylum June, 1881, age 50, single. Excitable, very talkative, disconnected ; thinks she has been poisoned by a certain doctor, who would put her out of the way if he could, that he might not be found out ; that she has recovered a large amount of money from him on a suit ; that the British Government has given her $15,000 to-day, that she was to be married to a lawyer last night and that another gave $2,000 to have her arrested because he wanted to marry her himself. She is below medium height and thin ; right pupil small and inactive to light, left one more dilated, also inactive. Previous history: Always considered eccentric, not ordinarily intelligent •, limited education, temperate habits, cheerful and frank. It is believed that a disappointment in marrying first caused her alienation. First decided symptoms observed twelve years ago ; delusion that she was going to marry some rich man ; she has grown thin and more demented, always harmless, happy and neat. October, 1881, marked delusions of hearing. She listens at the ventilators to peo- ple whom she thinks are talking to her. She says that her people are here ; she is quiet, tractable, neat. April, 1882, she continues to hear devils at times, and is noisy ; she scolds incoherently and breaks glass. November, 1884, she walks the floor, listening to voices which come from below ; she is much demented. She says she has five gifts in her eye, that she must walk all the time and be fed on bread and water ; left pupil large and immobile, lens cloudy. March, 1892, no great change, except that she is more 2 28 PARESIS FOLLOWING ORDINARY INSANITY. demented and senile. December, 1892, she had two epi- leptic convulsions, and has become untidy. January, 1894, she has had a few epileptic convulsions, usually at night ; she is much demented. April, 1895, she is very demented and weak ; she walks about and often falls and hurts her- self ; she is good-natured, very untidy. No convulsions lately. April, 1895, she had convulsions two days ago and another last night ; she has been in bed for three days in a weak, confused way. August, 1895, pupils unequal, left dilated, both inactive to light; articulation indistinct, knee-jerks absent, walk feeble. She stands without sway- ing with eyes closed ; feeble circulation, extremities blue and cold ; she is getting gradually weaker and more de- mented ; she died in October, 1895. (Abstract, Worcester, American Journal of Insanity, Vol. 52, p. 319.) THREE CASES OF GENERAL PARESIS AND CHOREA. In the first case, the patient had many attacks of chorea from infancy up to the beginning of his paresis at 33. In the second the paretic symptoms only partially a^ected the choreic ones. In the third case, the choreic move- ments were rhythmic or localized in a member in the form of paroxysmal attacks like the movements and contractions of Jacksonian epilepsy. (Abstract, Vallon and Marie, American Journal of Insanity, Vol. 51, p. 233.) Remissions. — In some cases remissions occur, usu- ally in the lirst or second stage of the disease, lasting from a few weeks to several months; even after a lapse of many years the disease has been known to return, but the average duration of a remission is from two to four months. A remission marks a ces- sation of active disease for the time, and many of the s3'mptoms disappear, but the disease is not eradi- cated, only quiescent, and is certain to reappear, usu- ally in a more active form. Some patients during a remission improve in mind and body equally; in REMISSIONS. 229 others the improvement in mind is noted without corresponding motor improvement. Remissions have been known so complete that every motor symptom disappeared and the mind seemed as clear as in health; these at times have been pronounced cures, but generally it is believed that the disease does not let go its hold on the system and that it is sure to return, sooner or later. Bland- ford says of some such seeming cures: "These cases would be pronounced sane by any jury. They have either lost their delusions, or are able to conceal them. I have received letters from such written without a mistake. But those who had best recovered are long since dead, and I know of no one whose disease did not reappear in a longer or shorter time." Remissions may occur at any time in the progress of the malady, but they shorten in duration as the disease advances. During these periods of cessation every trace of maniacal excitement and emotional display may cease, but some delusion frequently con- tinues; or a slight tremor of the lip or hand, an inequality of pupils, some defect in speech, or in gait generall}^ remains. If every other mental trace dis- appears, there sometimes develops some moral or esthetic eccentricity, i. e., purposeless lying, irritability of temper, extravagance in buying; or the only sign of disease ma}^ be a stolid or troubled expression. The patient is apt to grow stout in body and become more feeble in cold weather. Frequently the patient feels well; he converses intelligently, his interest in business returns and he desires to resume his former life. But if permitted to return to his occupation he soon becomes con- scious of a weakness in continued mental effort, or if it be manual work he finds the bodil}^ vigor does not return, and in either case he soon breaks down. 230 GENERAL PARESIS. It is agreed that the enfecblement of mind is incom- patible with perfect responsibility; that under the best conditions the engaging in business should be dis- couraged; that only quiet surroundings, free from ex- citement and anxiety, should be provided. Medical care and treatment should continue during the remis- sion, and a nurse or some responsible person should keep constant supervision, for the disease will surely appear again, and frequently its reappearance is marked by an outburst of excitement or violence, or by an epileptiform seizure. GENERAL PARESIS WITH MARKED REMISSION. A commercial traveller, with a history of drink, was ad- mitted with all the physical and mental symptoms of general paresis. He went into a stage of complete paralysis and then recovered so that he took a situation again at £300 a year : he held it for eighteen months, returned to asylum and died in a short time of general paresis (Whitcombe). REMISSION OF EIGHTEEN MONTHS IN SEA CAPTAIN. A captain of a steamer came to asylum in a maniacal state. After a few months of this excitement, with exalta- tion, he quieted down and seemed to recover perfect!}" ; he had no tremor or other signs of general paresis, although paresis was suspected. He commanded a ship eighteen months and the only difference noticed in him was that he was more placid and complaisant than formerly. He returned to England and rapidly broke down ; he became demented, had extreme tremor and in two months died of epileptiform convulsions. (Abstract, Whitcombe, Journal of Mental Science, Vol. 37, p. 4S7.) A REMISSION OF THREE YEARS OR MORE. A man, a?t. 31 ; after some eccentricities became mani- acal, with much exaltation, extravagant boasting, letter writing to the queen, masturbation, self-decoration, etc. In two years this condition subsided and he became taciturn REMISSIONS. 231 and hypochondriacal, with loss of expression, thickness of articulation, fibrillar tremor and incapacity for exertion. These symptoms vanished and for three years he has been in constant and responsible employment. (Abstract, Mortimer, Alienist and Neurologist, Vol. 10, p. 489.) A MARKED REMISSION AFTER THREE YEARS' DURATION OF THE DISEASE. Man, with well-marked symptoms of general paresis. The disease went on for two years and he nearly died of general convulsions but after a time began to improve ; he remained in asylum three years, then went abroad and when heard of some years later was still well. (Abstract, Rayner, Journal of Mental Science, Vol. 37, p. 487.) A REMISSION IN A MEDICAI. MAN. A medical man had marked symptoms of general par- esis, who had taken alcohol and all kinds of drugs. Gradually the symptoms passed away, he was discharged and two or three years after, he was again a " dispenser." (Abstract, Rayner, loc. cit., p. 488.) GENERAL PARESIS WITH REMISSION OF SOMATIC SYMPTOMS. A case in which, during periods of excitement and even in conditions of exaltation, the somatic symptoms, which at the best were very slightly developed, seemed wholly in abeyance. Competent experts could not be certain that it was general paresis, though it proved to be so. (Abstract, Stearns, op. cit., p. 512.) A REMISSION OF MORE THAN THREE YEARS. Patient, ast. 32, had been very restless and talkative, boasting of his riches and adventures. His account of his life was incoherent and contradictory. At the hospital he was singing and shouting and very destructive ; eight months after admission he had a paroxysm of maniacal violence. On admission, he had numerous exalted delu- 232 GENERAL PARESIS. sions, was king of the world, brothers were kings, could do whatever he tried, etc. ; speech thick, and articulation at times difficult; his gait very unsteady ; temperature 98° in the morning, and 99° in the evening. He was under treatment for a year when he began to improve and the exalted delusions passed awa}-. The thickness of speech and difficulty in articulation remained, although in a less degree, his legs still were weak. He remained under observation for another year when he was discharged. He kept well for over three 3^ears when he disappeared from observation. (Abstract, Bucknill & Tuke, Psycho- logical Medicine, p. 330.) A REMISSION OF THREE YEARS. THE PATIENT RETURNED TO BUSINESS. In one case, which has since been running rapidly a downward course, the remission lasted three years, during which time he attended to extensive commercial under- takings with fair success and took charge of several assign- ments. (Abstract, Spitzka, o^. at., p. 215.) A REMISSION OF FIVE YEARS' DURATION. Patient admitted, supposed to have general paresis ; maniacal excitement, inequality of pupils, blurring of speech, alteration of handwriting and knee reflexes af- fected. At the end of a year he had serious convulsions, with temporary loss of power on left side. He improved very much mentally and became apparently well but re- mained as a voluntary boarder until a few weeks ago — over five years. Then he became excitable ; handwriting changed, left out words and letters. He is occasionally wet and restless ; he is unmanageable, tumbles about, and he has exalted ideas and schemes. (Abstract, Whitcombe, loc. cit., Vol. 37, p. 487.) A CASE OF GENERAL PARESIS WITH A REMISSION OF MORE THAN NINE YEARS. The patient had usual delusions, twitches of facial mus- cles, tremor of upper lip, thick speech, and weakness of REMISSIONS. 233 the knees, and was violent and destructive. He gradually calmed down, became quite rational, and lost all abnormal symptoms, except the tremor of lip and slight thickness of speech. He was ill for three months and was kept under observation six months before he was discharged. He is still alive, nine years since discharge, and draws his pension regularly. (Abstract, Bucknill & Tuke, of. cit., P- 330-) A COMPLETE REMISSION OF LONG DURATION. A patient had been transferred to an asylum eleven years before, certified to be suffering from general par- alysis. There was nothing which militated against such a diagnosis except that the man gradually improved, was discharged and for years after supported himself by his handicraft. (Abstract, Blandford, op. cit., p. 307.) A remission more or less prolonged sometimes fol- lows fracture, abscess, erysipelas or some other inter- current disease or episode. GENERAL PARESIS WITH IMPROVEMENT FOLLOWING CARBUNCLES. - A man with general paralysis, who had been in the asylum three years, developed three carbuncles and was expected to die, but is now getting better. (Abstract, White, Journal of Mental Science, Vol. 37, p. 488.) REMISSION AFTER A LARGE CARBUNCLE. Hurd, H. M., has reported a case of remission after the patient had had a large carbuncle over the cervical verte- bras. (Abstract, Stearns, op. cit., p. 508.) GENERAL PARESIS IN WHICH MARKED IMPROVEMENT FOLLOWED ABSCESSES. A man had passed through the early stages and his friends were awaiting his death. It was a question whether to let him die as he was or to evacuate three or four ab- scesses which he had. It was decided to evacuate them, 234 GENERAL PARESIS. and he at once improved and has remained in a somewhat weak-minded condition for about six years. He can now play tennis well. (Abstract, Savage, Journal of Mental Science, Vol. 37, p. 488.) A CASE OF GENERAL PARESIS IN WHICH A MARKED RE- MISSION OCCURRED AFTER AN EXTENSIVE SLOUGH. Male, get. 40 ; married ; native of Michigan ; formerly hotel proprietor and of average business capacity. His mother was intemperate and her family subject to phthisis. He was also intemperate, reckless in his expenditures and led a fast life. After marriage, he reformed but did not suc- ceed in business. There was no history of syphilis. After two years of mental infirmity, he was admitted to asylum. At first, he had been depressed and indifferent to business. After a year, he developed delusions of grandeur. His bodily health improved, while his mind grew weaker. Pre- vious to admission, he had remained in bed for several weeks and had shown a great tendency to sleep. On admission, he weighed one hundred and seventy-seven pounds ; height medium ; bodily health fair ; pupils contracted and right larger than left ; skin dry ; articulation thick and in- distinct ; temperature 99^ ; great ataxia ; expression dull and heavy; fine facial lines absent; replied to questions in a drawling way and often his replies were irrelevant ; he had delusions of grandeur and he thought himself in perfect health. One month after admission, he was depressed, and sat quietly alone, apparently reading. He showed stupidity and torpor, was dull, anxious to go to bed and would fall asleep even while eating. Extreme debility and paresis were present. He required constant personal attention. His articulation was clumsy and his voice weak. His condition passed into elation. He became mischievous, threw clothing from the window, appropriated others' property. On January 6th, about a year after ad- mission, he had an apoplectiform seizure, with choreiform movements of the head, twisting of the mouth, protrusion of the tongue and tossing of the arms. The axillary tem- perature was 103'^ ; pulse rapid ; pupils contracted. Tenth, REMISSIONS. 235 continues fairly comfortable in bed, with no convulsive move- ments. He is eating well and feeling <' first rate." Four- teenth, he sits up and pretends to read a paper. Twenty- first, he does not recognize an old acquaintance. He is very untidy. February, he is able to be about ; quiet ; very feeble in mind ; inclined to sit alone ; inappreciative of what is said to him ; gait feeble. He has sudden im- pulses to do violence. His handwriting is totally illegible. March, he is again elated and extravagant ; he forms strange intimacies and promises feeble-minded patients work at immense wages. During April, he had rheumatoid affec- tion of the joints. He was confined to bed and grew de- bilitated. There was tendency to engorgement of the right lung. May, he is able to be about. June, he is better mentally than at any time since coming under treatment ; quiet, appreciative, and able to care for himself; attends chapel and entertainments ; he is neat in dress ; he shows a disposition to assist in work ; he can remember names. The improvement fallowed the formation of a large gan- grenous slough on the left heel. His articulation and gait are much better. He can write legibly. He is able to write letters ; mind is quite clear ; he is contented and cheerful; he has no delusions. August, he thinks himself well enough to be discharged but is not strenuous about going away. His writing improves. September, he is industrious and pleasant ; enjoys the freedom of the grounds ; plays croquet. On November 25 he was re- moved by his wife on trial. She regards him as well. His mind is not strong but the progress of the disease seems arrested. After his return home, he took care of horses. He had limited endurance, but could contribute materially to his family's support. Thirteen months after his dis- charge, he was in good flesh and seemed as well mentally as when he left the asylum. He has been working more or less ; he shows a pleasant interest in the institution ; re- cently he has experienced pain in the heel on which the slough appeared. Present condition about two and a half years after discharge — he has improved mentally ; he has been out of employment but a few months since he left the 236 GENERAL PARESIS. asylum; except for catarrh, he is in good bodily health; weight 165 pounds; no paresis in speech or gait ; hand- writing regular ; he has full control of a livery stable and earns good wages ; he keeps his books accurately ; and he has good memory for remote and recent events. His dis- position has changed. He used to be irritable and quick- tempered, but is now always good-natured. His habits are temperate and regular. (Abstract, Burr, C. B., Ameri- can Journal of Neurology and Psychology, 1884.) Duration. — It is difficult to mark a general average in the duration of this affection, for many factors combine to effect its progress. The special form taken by the disease in any case has probably the greatest influence as to the length of time required for it to run its course. The so-called ascending form, i. e., when the spinal cord is affected first, is slow. If brain and cord are attacked at the same time the duration is usually short. Cases with expansive or exciting delusions proceed with greater rapidity than those of the depressed form. Again the average course of the disease is longer in women than in men, in those who have lived a life of comparative comfort than in the poor, and in hereditary cases than in those not hereditary. All factors of a violently disturbing nature hasten the end, while all quieting influences such as the environment of isolation, cessation of business trials, and absence from home cares tend to prolong the life. Perhaps there is no factor which modifies the duration so largely as remissions, which may vary in length from a few weeks to many months. One of the difficulties of determining the duration is frequently the impos- sibility of fixing the time at which the disease actu- ally began. The prodromal stage may run but a few months, sometimes a few years, and it is said in very exceptional cases that it may last nearly a life- DURATION. 237 time. Archer gives the order of duration ascending as follows: Cases marked by excitement, by depres- sion, by uniform dementia, by alternating excitement and depression, and by apoplectic attacks. The disease is progressive and if uninterrupted by remissions, or other favoring circumstances, the patient goes steadily down to death, probably before two years from the time of the established disease. It is said that more patients die under two than over five years after attacked, but cases have been pro- longed to ten, or even fourteen years or more; how- ever, a case lasting ten years is very unusual. Clous- ton says : " So far as I am aware, no case with every mental and bodily symptom of general paresis, and diagnosed by many competent and experienced specialists to be such, ever lived so long as thirty years." Blandford gives an account of a patient, who lived twenty-seven years. French authors regard the average as less than two years, and some English writers place it at twenty-two months. Dercum says : " Males generally die within two or three years, females within three or four, while the great majority of all cases die within five years. Nothing more definite can be said than that the end may come within a few weeks after inception, either from maniacal exhaustion, a cerebral seizure, or decline of vital powers, or it may be prolonged; some- times the patient is relieved by weeks of comparative freedom from disease, but it may be that he drags out weary months of continually increasing helplessness in both mind and body. A CASE OF GENERAL PARESIS OF LONG DURATION. A. B., get. 55, merchant, no history of syphilis; tem- perate ; insanity on maternal side of family. The family noticed, ten years before his death, that his speech was 238 GENERAL PARESIS. clumsy and unintelligible, his walk was uncertain and hands unsteady. He made expansive statements as to his business ; showed less restraint in the use of money ; became very social ; showed anxiety for nothing. Two 3'^ears later, a diagnosis of paresis was made. The patient continued in business and, except that he began to lose in- terest in his affairs, no further mental symptoms developed. Speech was jerky and scarcely intelligible ; movements of upper and lower extremities became very ataxic so that he was scarcely able to feed himself or walk without assistance. Examination during the last five years of life showed ex- cessive tremor of tongue and muscles of face ; ataxia and tremor of arms with ataxia and exaggerated reflexes in legs ; pupils normal ; speech more unintelligible ; had maniacal and epileptic seizures several times a year. (Abstract, Fisher, E. D., Journal of Nervous and Mental Diseases, Vol. 18, p. 824.) GENERAL PARESIS OF LONG DURATION. Savage gives a case of general paresis of long dura- tion which was marked by severe convulsions, recurring during the greater part of the disease. Death occurred at the end of nine years. A CASE OF PARESIS OF FOURTEEN YEARS' DURATION. Brush and Sinkler conjointly report a case of gen- eral paresis of fourteen years' duration. It was marked throughout its course by numerous epileptiform convulsions. (Abstract, American Journal of Insanity, Vols. 45 and 46.) GENERAL PARESIS OF LONG DURATION. M. Lapointe observed a case of general paralysis of unusual duration in which the cardinal symptoms had grad- ually disappeared and had been replaced by simple de- mentia. The autopsy verified the diagnosis after the dis- ease had lasted fifteen years. (Abstract, Journal of Ner- vous and Mental Diseases, Vol. 24, p. 314.) PROGNOSIS. 239 A CASE OF GENERAL PARESIS OF LONG DURATION. A patient who had general paralysis for sixteen years was a typical case, with periodical attacks of violence, sending telegrams continually, writing in a general par- alytic style. (Abstract, Briscoe, Journal of Mental Sci- ences, Vol. 53, p. 883.) A CASE OF GENERAL PARESIS OF LONG DURATION. Lapointe related a case of general paresis lasting for twent3'-iive years, the diagnosis being eventually con- firmed by post-mortem examination. (Abstract, Journal of Mental Science, Vol. 43, p. 383.) A CASE OF GENERAL PARESIS WITH A LONG PRO- DROMAL PERIOD. A baronet, who had shown symptoms of brain affection and epileptiform attacks, so far back as 1856, lived until 1883. (Abstract, Blandford, of. ciL, p. 299.) Prognosis. — The prognosis is uniformly unfavorable. It is regjarded as one of the most fatal of diseases. According to Ziehlen some years ago there were but a dozen cases of recovery on record. Spitzka gives an account of one, a rheumatic patient whom he treated five years after his discharge, and was unable to find any trace of general paresis in him. Another instance he records of a general paretic in Australia, who had escaped from the asylum, and five years later paid them a visit to show that he had recovered. Other authors report a few cases whose histories were followed for from six to ten years after discharge and no relapse had occurred, but one of these same authors expresses his doubt as to their having been genuine cases. It is the opinion of some writers that these and similar ones were not cases of true recovery. When death comes within two or three years after discharge the belief by them is that the patient dies 240 GENERAL PARESIS. in a period of remission, and had he lived a little longer the disease would inevitably have returned, for from its nature it is necessarily progressive and fatal. Blandford says, " patients are dying of it (paresis) in all the as3'lums by the hundred 3'et the best authorities record no recoveries." A few cases of severe injury, or intercurrent disease, have been known to cause a form of recovery but it is after all only an arrest of the progressive enfeeblement, and the mental defect in time goes on. Remissions offer a ground of hope, but in a great number of cases they are rare, and after each remission the disease re- appears in a more intense form. General paresis is thus far one of the most unfavorable forms of insanity as regards recovery and the duration of life. SUPPOSED RECOVERY. Simon cites the case of a patient who had a remission and remained well for twenty-five j^ears. A CASE OF GENERAL PARESIS WITH MARKED REMISSION, AFTER SUPPURATION THAT RESEMBLED A RECOVERY. D. Mc, married, get. 50, railway agent, no insane in- heritance, the first attack of insanity requiring seclusion, although he had been peculiar for years before. Cause, over- work ; sober, industrious ; no syphilis ; first symptoms were excitement, incoherent, rambling conversation, exalted ideas of wealth and station ; benevolent, thought he had a secret which would benefit the human race. On admission he talked incessantly, with wild exaltation ; he was sleepless, haggard, restless, and unable to stand still for a minute. He was treated with hyoscyamine without benefit, was in- coherent ; left pupil large ; speech hesitating ; took several hours to finish a short letter; wet and dirty at times, mem- ory became worse. In three months he had a huge car- buncle on back of his neck ; no sugar in his urine. After the carbuncle, his symptoms improved. He was discharged TERMINATION. 241 well in five months' time. Some months later, he was al- lowed to manage his own affairs. He is now under treat- ment for anomalous parah'tic symptoms, supposed to be due to syphilis, but is without mental disorder four years after discharge. (Abstract, Savage, o^. cit.^ p. 322.) APPARENT RECOVERY FOLLOWING EXCESSIVE SUPPURATION. In the only case of general paralysis that Savage says he ever saw, which apparently recovered, one symptom — cranial nerve paralysis — pointed to syphilis, though there was no other proof of the disease. The man got well and remained well for years, but died of obscure nervous disease, which was looked upon as specific. In another case with specific history prolonged remission has occurred and in both of these cases, excessive suppuration was the immediate cause of relief. (Abstract, Savage, of. cit., p. 322.) A CASE OF PARESIS WHICH PRACTICALLY RECOVERED. A patient with typical S3'mptoms of general paralysis, after six or eight months' treatment, was discharged on leave. After a year's leave of absence he was in command of a ship and his former employers could detect no loss whatever of his faculties. (Abstract, Savage, loc. cit.^ Vol. 5, p. 402.) APPARENT RECOVERY FOLLOWING A CEREBRAL SEIZURE. Recovery occurred after an apoplectiform attack in a case of Schules. (Abstract, Spitzka, of. cit., p. 216.) Termination. — Death may come in one of many forms to terminate the course of the disease. It may com.e suddenly, in an apoplectiform or an epileptoid seizure, in paralysis of the heart, or even in choking, or the end may be hastened by tuberculosis, pneu- monitis, edema of lungs, acute intestinal, renal or vesical troubles, deep bed-sores, septic infection. 242 GENERAL PARESIS. or by embolism, erysipelas, phlegmon, suicide or trauma. Extended dementia, or the alternating form of paresis, may prolong the duration, and the end come, finally, from simple exhaustion due to the general disease. Cases strongly hereditary run a longer course, and, as has been said, remissions sometimes postpone for years the fatal termination. " The dis- ease is special," says Savage, " in so far that it ends fatally in nearly all cases, and in almost always the same way; and that, whatever the earlier symptoms may have been, the later ones are similar to a re- markable degree." GENERAL PARESIS, DEATH IN THE MANIACAL STAGE ; DURATION ABOUT A YEAR. F. C, aet. 40. Surgeon in Indian army; was in the massacre of Cawnpore, escaped and underwent many risks and hardships. Some time afterwards, his friends wrote that he was much altered in behavior, subsequently, that he had a sunstroke. Ten 3'ears later and a year before admis- sion he was induced to come to England ; on the voyage he behaved curiousl}'^ ; also, his wife died, an event which seemed to excite him very much, and his behavior called for the interposition of the ship's authorities. On his arri- val, his youngest child died. At home, he would carry his children around on his hip in the Indian fashion, calling on acquaintances and talking in an excited manner ; he be- haved strangely to his mother's servants, whom he alarmed. He invited women whom he met at night into his mother's house. Condition on admission : Five feet ten inches high, defective vision, some obliquity of the balls, and amaurosis of left eye ; dark complexion ; he has hemorrhoids and is subject to prolapsus ; good pulse, no difficulties of digestion or chest signs. He talks incessantly about himself, his plans which he continually changes ; he talks to everyone he meets, to his servants of his own affairs, which are of Utopian character ; he has marked elation of spirits and TERMINATION. 243 feebleness of intellect ; he talks much about marrving, thinks every woman he sees would exactly suit him and has made several proposals ; he will extol and abuse the same person in the same breath. Expression, sleek ; facial mus- cles relaxed ; at first he refused to leave his home and became excited and angry, then came voluntarilv and was easily persuaded. After arrival, he soon made himself at home, soon found occupation ; he groomed his own horse, was agreeable and sociable but talked continually of his skill and reputation and wealth ; he is very close in spend- ing his money, which is his normal character. After three months : Mental characteristics the same, less excite- ment, a total absence of reticence. Occasionallv he slurs in speech, eats largely, reads novels chiefly, and repeats the incidents to everyone. After six months : Health con- tinues good, stammers rather more, mind weaker ; he is full of a plan to make his escape and tells everyone about it; he eats enormously, rides and drives out dailv. Eight months : He went into a public house leaving his horse with the attendant and bolted across the fields : he was found at his mother's, and brought back ; mind more fee- ble ; he made offers of marriage to two ladies in the pres- ence of both. He writes numerous letters which are less connected in matter. Tenth month : He is more restless and irritable, more feeble, talks more of his great wealth and schemes ; he was discovered concealing a pair of boots ; his speech is more affected, with increasing difficulty in pronouncing the labials. Ten and a half months : After a bad night, he was excited early in the morning. Ex- citement continued during the next day ; he again broke out, tore down the shutters in the night, threatened to mur- der the first person who came near him ; he is highly ecstatic, very libidinous and elated, says he will be Em- peror, that he will marry the Queen, and fifty other women. Motor difficulties well marked, articulation mumbling ; next day he was calmer. Five days after the outbreak, he has continued excited and at times raves, talks inco- herently, and imagines himself in communication with God, whom he addresses in a familiar conversational way ; 244 GENERAL PARESIS. he takes food well, but sometimes pours his soup, wine or medicine on his head. He does not exhibit so much sexual excitement, motor symptoms continue. February 5th, weakness increased ; he complained in the evening of a sore throat and asked to have it examined, but spoke with a firm voice ; shortly after, his powers quickly failed and he died from exhaustion. (Abstract, Sankey, o^. cit.^ P- 319-) A CASE OF GENERAL PARESIS WITH A PERIOD OF COM- PLETE REMISSION. THE DISEASE RETURNED AND CONTINUED TO A FATAL TERMINATION. Henry J. C, single, aet. 29 ; has one sister insane. The cause of present attack unknown ; he has been a commer- cial traveller, intemperate, and worked very hard. The first symptoms appeared in August; he began to mope, and felt unable to do his work ; he ate well, but slept badly. After the period of depression, he became emotional, excit- able and threatening, also extravagant and generous ; sleep became profound ; he indulged sexually to a great extent ; thought he was Christ. On admission was maniacal, dirty and destructive. An abscess hard to heal, con- taining gummous unhealthy looking pus, formed on his leg. Narcotics and sedatives had no effect until the period of excitement passed off of its own accord after severe purging and vomiting. In July, a year, he was reported convalescing ; in two months he was sent on leave ; the leave was extended until November, when he was dis- charged. He had not recognized the fact that he had been excessively violent and dangerous. He was re-admitted in September two years ; he had been hard at work for a year, and had suddenly become extravagant, restless, and had ideas of grandeur. On admission it was found that his speech was greatly affected ; he talked freely of his mil- lions, and he was grand, benevolent, and demonstrative. At the beginning of the next year he lost strength and flesh, but no physical disease could be detected. Early in February, he wet his bed and had an epileptic fit marked TERMINATION. 245 by half-open eyelids and lip muscles, inversion of right thumb, clonic convulsions of hands and feet ; pupils minute, right the larger, and temperature 98°. In the evening of the same day, the fits returned, affecting both extremities ; breathing was rapid, skin sweating ; temperature 108°. 5 ; he then died. (Abstract, Savage, o^. cit.^ p. 304.) CHAPTER XVII. PATHOLOGY AND PATHOLOGICAL ANATOMY. Pathological Anatomy. (<-?) Macroscopic. The Brain. — The bone of the calvarium is in a pro- portionate number of cases, one third in the large series observed by Mickle, increased in thickness and density, with disappearance of the diploe. In a much less number it is thinner than normal, and very rarely it is abnormally soft. Often, also, the bone is con- gested and its inner surface may have a worm-eaten appearance. Occasionally there may be a distinct deposit of new bone, either in the form of a layer, or of one or more exostoses, on the inside of the inner table. The dura is frequently thickened and vascular, sometimes but slightly. According to Mickle this change is found in about one half the cases. In a smaller number, one fourth, it is also more or less tenaciously adherent to the bone, between which also (dura and bone), there may be numerous vascular connections, consisting of thickened and tortuous vessels. The internal surface of the dura often shows evidences of internal pachymeningitis, usually of the hemorrhagic variety. This may be evidenced by either the existence alone of the characteristic false membrane and reddish-brown stainings, which mark the seat of previous hemorrhages, or more rarely, in addition marked hematomata, which may be present either externally, or internally, or both. 246 THE BRAIN. ' 247 In the subdural space there is an increase of cere- brospinal fluid, which may be either pellucid or turbid. The arachnoid is always more opaque and usually is much thicker and tougher than normal, and either mottled with white spots, or striated along the fissures with white fibrous appearing bands. These changes are more marked over the fi-onto-parietal con- vexity and internal surface of the hemispheres, and often the interpeduncular space is bridged by a tough thickened arachnoid. Calcareous plates are occasion- ally found in the membrane. Under the arachnoid, especially over the fronto- parietal regions of the brain, are seen covering the pia numerous varying sized dilated and congested vessels, 13'ing in what appears like a milky or opaque jelly; if the arachnoid is perforated this material oozes out as a dirty opaque fluid. The pia is greatly thickened and may occasionally contain, either small bony plates, firm, fibrous, whitish nodules, or a few patches of lymph or pus. When the membrane is removed from the brain substance an intense edematous con- dition is found everywhere present, both in the fissures and over the surface of the convolutions and per- meating the cortical substance. The membrane no longer readily separates from the brain cortex, but is adherent to it, especially over the apices of the con- volutions, and the attempt at removal brings away also bits of the adherent cortex. These changes are well shown in Plate XII. The lobes of the brain, also, often are adherent one to the other, such cohesion being especially common between the frontal lobes. In very acute cases these cerebro-meningeal adhes- ions may be absent and the meningeal changes con- sist of a slighth" opaque arachnoid, an edematous and congested pia. In such cases the brain may appear to be increased in volume, owing to the intense 248 PATHOLOGY AND PATHOi^UlilCAL ANATOMY. congestion and edema and, if the dura is removed, it may be impossible, owing to the projecting brain, to replace the calvaria. These changes, instead of involving entire lobes, may be confined to isolated areas. In the more chronic forms, which are the more common, the brain is more or less flaccid, smaller and lighter than normal. The appearance of the brain cortex varies, the changes being most pro- nounced in the frontal res^ion and shadino^ ofl' tjradu- ally toward the normal, as we pass backward. The one practically constant feature, ninety-four per cent, in Mickle's series, being that it is much reduced in thickness. The convolutions are also thin, shrivelled, or flattened. It may be softer, either in whole or in parts only, more rarely it is indurated, either in small areas, or diflusely, when it gradually shades oft' to normal, or to lessened consistence as we examine from the frontal towards the occipital region. Usu- ally it is the seat of areas of hyperemia of more or less irregular distribution, but may be anemic. In the former case its color would be reddish, in various degrees, or mottled, while in the latter it is either pale, fawn color, dirty white, or slate colored. The strata are often indistinct. The cortex is found hyperemic and softened in cases of comparatively brief duration, the longer the course of the disease the more apt we are to find it indurated and anemic; some authorities, Clouston and Berkley among others, describe the latter as the condition more commonl}' met with. Where the pia has been adherent the convolutions present an irregularly eroded appearance; as Clouston expresses it, they resemble the surface of a cheese where a mouse has been. This tearing oft' of the cortex has been termed decortication. The erosions may be red in color, or Plate XIL APPEARANCE OF PORTION OF VERTEX OF THE BRAIN IN ADVANCED PARESIS. (Clouston.) a. Skull-cap condensed, b. Anterior third, showing thickened milky arachnoid, dotted over with small white spots, with tortuous dilated vessels, and turbid fluid beneath, c, Middle third, showing the appearance after pia has been removed. The outer layers of gray matter have been torn away in irregular patches, adhering to the pia and removed with it. The parts so removed have left ragged eroded-looking spaces, d. The pia stripped from middle third, concealing posterior lobe, and showing the appearance of its inner surface with portions of the convolutions adhering to it. It is a tough, thick, spongy-looking texture, instead of the normal delicate, filmy, transparent membrane. THE BRAIN. 249 pale, according to the progress of the disease. They are most common in the frontal and parietal lobes and the gyri about the olfactory bulbs at the base, but may occur elsewhere. Mickle claims that they do not always correspond to the adhesions on the sum- mits of the gyri, but may be found at the bottom of the fissures. Sometimes the entire depth of the gray matter comes off, leaving the white matter beneath. Decortication in greater or less degree, is the most characteristic and frequent of the gross lesions of paresis, but is not pathognomonic. The white matter, as the gray, may be either of diminished consistence, when it is hyperemic and reddish, or mottled in color; or of increased consist- ence, when it is of an unnatural whiteness and may display a sieve-like appearance. The ventricles are dilated, filled with fluid and the ependyma is thick- ened, roughened and tougher than normal. In marked cases it is covered with granulations and feels dis- tinctly rough to the touch. This condition is usually most marked in the floor of the fourth ventricle and there it often presents a grayish gelatinous appearance. The ganglia at the base of the brain are often atro- phied and they may be either softer or harder than normal. The pons and medulla-^ niay also in some cases be the seat of morbid changes, either softening or induration being present, more rarely distinct atrophy may be seen. Similar changes are sometimes found in the cere- bellum. Mickle claims to have found adhesions ol the membranes to the cerebellum in forty-four per cent, of his cases. Other writers deny that cerebellar adhesions occur. 1 That the pons and medulla are anatomicalh' parts of the spinal cord is believed by the writer, but as in most text-books they are considered as parts of the brain, they are here so included and will be, also, when the microscopic changes are described. 250 PATHOLOGY AND PATHOLOGICAL ANATOMY. The olfactory bulbs and tracts are often atrophied and softened, and similar changes have been found in the optic nerves. The prominent macroscopic changes in the brain and its membranes may be summed up as follows : 1. Thickening of the dura, with internal hemor- rhagic pachymeningitis (about fifty per cent, of the cases). 2. An increase of the fluid in the subdural space and meshes of the arachnoid. 3. Opacity and thickening of the pia with adhe- sions to the cortex, causing portions of the cortex to adhere to the membrane, when it is stripped off (decortication). 4. General flaccidity and diminution of the weight of the brain and marked narrowing of the cortex. 5. Areas of softening and hyperemia and of undue firmness and anemia scattered over the cortex. 6. Dilatation of the ventricles, thickening and roughening of the ependyma and increase of fluid within them. The Spinal Cord. — As has been noted in discussing symptomatology, the prominence of spinal symptoms varies. In those cases in which they are slight, the morbid anatomical changes present are slight, in those in which they are prominent, the changes in the cord and its membranes are likewise prominent. Alterations of some sort are found in most cases. The following changes may be present. The men- inges are often thickened and h3'peremic, opaque, granulated and adherent to each other and to the cord. These appearances are more apt to be found posteriorly. In a small number of cases evidences of hemorrhagic pach3'meningitis, in the shape of re- cent or old clots, may be found. Clots are some- times also found extra-dural. THE BRAIN. 25 1 The thickened pia surrounds the spinal nerves as they emerge, forming, as Mickle expresses it, muffs for them. In acute cases the spinal membranes may be red- dened, thickened, somewhat opaque and markedly edematous. Mickle found in two thirds of his cases softening of parts of the cord; in one third, he found induration and in from ten to twelve per cent, atrophy. Either hyperemia, or pallor of the cord substance, may be found in a few cases. In a"^considerable number of cases, 15.9 per cent, according to Bevan Lewis, sclerosis of the posterior columns and of the dorsal and lumbar posterior nerve roots, with thickening of their sheaths, similar to that in tabes, is found. When found, the sclerosis is usu- ally most marked in the lower part of the cord, becoming narrower and more confined to the columns of Goll as it ascends, to cease at the floor of the fourth ventricle. In other cases the sclerosis is con- fined to the posterior commissural zone and the pos- terior median columns (columns of Goll), the root zones escaping. ' More rarely a secondary descending degeneration of the pyramidal tracts occurs either alone, or asso- ciated with the posterior sclerosis. Either a diffuse slight sclerosis, causing generally increased hardness, or a slight diffuse myelitis, causing general softening, may be occasionally present. Atrophy of parts of the gray matter, especially the horns, is sometimes present. (d) Microscopic. The Brain. — The microscopic changes found in gen- eral paresis are manifold ; none however are strictly characteristic of the disease and it is doubtful if it 252 PATHOLOGY AND PATHOLOGICAL ANATOMY. can positively be diagnosed with the microscope.^ The main interest, of course, attaches to those found in the pia and cortex. These changes may be classi- fied as follows: 1. Those in the blood-vessels of the cortex and pia, and the perivascular or 13'mph-spaces. 2. The neuroglia. 3. The nerve cells and fibers. I. The Blood-Vessels. — The walls of the capillaries are thickened and present a granular appearance, with an increase in the number of nuclei that are normally present there. (See Plate XIII., Fig. 2.) Fre- quently there is some migration of leucoc3'tes, which are found in the perivascular spaces. The adventitia of man}^ of the pial and intra- cerebral arterioles is, according to the state of the disease, infiltrated more or less densely with small round cells, which in marked examples are found also in the neighboring nervous tissues. In advanced cases the cells may be so dense that the vessel wall is hidden; indeed, Mickle has compared the appearance to that of a muft' surrounding the vessel. This infil- tration is probably due to a periarteritis. (Plate XIII., Fig. 3.) The perivascular, or lymph spaces finally become full of these cells, so that finally many of them become impervious to the passage of the lymph. Hematoidin and cellular debris are also found in these spaces. Some, owing to the pressure of the fiuid in attempt- ing to get through, are dilated. In addition to the vessels so affected W. Ford Robertson^ lays stress upon the large numbers of capillaries and arterioles that are aflfected with that form of degeneration known as hyaline fibroid degen- 1 V/de O. Schmidt, Allgemeine Zeitschrift fiir Psvchiatrie, 54, 1897- 1898, p. 178. 2 Pathology of Mental Diseases, p. 140 et seq. THE NEUROGLIA. 253 eration, or arterio-capillary fibrosis; this, while present to a greater or less extent in all persons after middle life, is especially prominent in cases dying of general paresis. It is characterized by the proliferation of the endothelial cells, the formation of new fibrous tissue, and finally by a hyaline degeneration of these cells and fibers, causing the vessel to present a thick- ened, vitreous appearance. In the arterioles and venules affected with this form of degeneration the adventitia is converted into a broad, homogeneous band of regular outline. In these vessels there is also usually some degeneration of the middle coat. The short vessels of the first layer of the cortex are particularly affected. Other vascular changes, not so commonly met with, are pigmentation of the vessel walls; dilatation of the vessel; obliteration or narrowing of the lumen. 2. The Neuroglia. — Those elements of the neuroglia known as Deiters', or spider cells present marked changes in the affection that we are considering. Bevan Lewis ^ terms these cells and their processes the " lymph connective tissue of the brain " and first advanced the view that they play some part in " the reabsorption and distribution of the effete material and surplus plasma." By means of methods de- veloped by him, it is found that these cells throw off two sets of processes: (i) "An enormous number of extremely delicate fibers, which spread into the intervascular area around, and (2) a much thicker, coarser process, which often, after a tortuous course, ends in the adventitial sheath of the blood-vessel." (See Fig. 4.) These processes, in crossing the perivascular canal, give off a number of delicate proc- esses that traverse the canal. This view of the 1 Mental Diseases, 2d Edition, p. 98 et seq. 254 PATHOLOGY AND PATHOLOGICAL ANATOMY. Swollen deoenerated Nerve-cell. Vascular process of Spider-cell Spinous extensions from vascular walls. Oegeneratlng Nervs- cells attacked by Spider-cens. Spider-cell with Its vascular process. Arteriole surrounded by Spider element*. DEGENERATION OF NERVE-CELLS IN CORTEX WITH PROLIFERATION OF THE SPIDER OR SCAV- ENGER-CELLS. SECTION FROM FIFTH CORTICAL LAYER OR MOTOR REGION. X 210. (BEVAN LEWIS.) THE NERVE CELL. 255 function of these cells has been accepted by other, but not by all pathologists. In general paresis there is a general hypertrophy of this system, the cell body becomes considerably en- larged, often exhibiting subdivisions of the nucleus, and stains much more deeply with aniline than does the normal cell.-'^ The processes also stain deeply and the vascular processes, which stain still more deeply (those attached to the blood-vessels), are in- creased in size and often in number and are seen to be attached to the vessel b}' a nucleated mass of protoplasm. The other processes are often seen to surround and embrace the nerve cells. (See Fig. 4.) These changes occur in the later stages after the perivascular spaces have become blocked up, (see p. 252) and it is proper to state are not always found markedly developed. In a series of sixty-four cases, examined by Ford Robertson, only one third showed them to a great degree. According to Bevan Lewis ^ they are due probably to an effort of these cells to remove the effete materials and cellular debris that are found in the brain from degenerated nerve cells, and whose removal is hindered by the obstruction of the perivascular spaces or lymph chan- nels. He often speaks of them as "scavenger cells." 3. The Nerve Cell. — Various forms of degeneration of the neurone are met with, all of which may also be found in other conditions. That most commonly met with is the pigmentary or yellow globular. Bevan Lewis was the first to lay stress upon this form, which he termed pigmentary or fuscous. It consists in the early stages of the formation below the nucleus of a quantity of yellow pigment; at this time also the 1 Normally the cell body and processes, i. e., Deiters' cells, do not stain at all with aniline, the nucleus alone staining faintly. "^ Loc. cit., p. 183. 256 PATHOLOGY AND PATHOLOGICAL ANATOMY. cell body becomes swollen, and the protoplasm stains more deeply than normally. As the process con- tinues the amount of pigment increases, the nucleus is displaced and even it sometimes becomes pig- mented. The protoplasm stains more faintly than nor- mall}^ (chromatolysis) and the processes begin to dis- appear until finally none are left, the nucleus disin- tegrates and the cell becomes a mass of translucent colorless finely granular material that practically does not stain at all. (See Plate XIII., Fig. 5.) Bevan Lewis believes that the pigment accumula- tion is " invariably a witness of bygone functional activity " and that its increase is due to an over- activity of the cell. This view is also held by Schafer, but is combated b}' many pathologists, not- ably Marinesco and Robertson. The difierent stages in the process have been well summarized by Bevan Lewis^ thus: Period of Over- Activity? — (i) Swelling of cell with increase of pigment. (2) Advancing degenera- tion, cell more globose, protoplasm retracting. Scle- rotic investment of cell and cincture formed. Period of Diminished Activity. — Nucleus eccen- tric, deformed, fatty, with narrow encircling zone of protoplasm. Processes few; these, as well as cell- protoplasm, faintly stained. Period of Absoi-ption. — Fatty transformation and decoloration of cell. Atrophy with shrinking or rup- ture into a heap of granules. Agapofi', who examined the brains of six cases of general paresis, lays stress upon the number of the ' For further description of this process see Mental Diseases, 2d Edition, Bevan Lewis, p. 527 et seq.; W. Ford Robertson, Pathology of Mental Diseases, p. 243 et seq. *It must be borne in mind, as has been before stated, that many pathol- ogists do not believe in the existence of a period of over-activity, but that the entire process is due to one of diminished activity. THE NERVE CELL. 257 pyramidal cells in which the gemmiiles of the den- dritic processes were either lost entirely, or were diminished in number.-^ There is also disappearance of the medullated fibers in portions, principally the frontal and antero-parietal of the cerebral cortex. There is considerable loss of the tangential and also of the radial fibers. This is but a natural consequence of the degeneration of the cell bodies above described. In the nerve fibers of the white matter changes are also found. Patches and streaks of gray degeneration were found in the immediately subcortical substance and Tuczek ob- served a like degeneration in the fibers between the cortex and medulla, which sometimes appeared as a gray streak or stripe. Similar changes mav be found in the corpus callosum, fornix, septum lucidum and crura cerebri. In the optic thalami, corpora striatse, pons, medulla and cerebellum, vascular changes and cell degeneration, similar to those occurring in the cortex, are more or less markedly present. Degeneration of the cells constituting the bulbar nuclei is a most common lesion. Its relationship with many of the characteristic physical symptoms, viz: weakness of the facial muscles, tongue, etc., is apparent. The important microscopic changes in the brain may be summarized as follows : An increase in the number of nuclei in the walls of the capillaries with a thickening and granular appearance of their walls. A more or less intense round-cell infiltration of the adventitia of the arterioles. Blocking up of the peri- vascular, or lymph, spaces with leucocytes, hema- toidin and cellular debris, with here and there dilata- tion of these spaces. An affection of other vessels ^Neurolog. Centralblatt, April i, 1S99. - 258 PATHOLOGY AND PATHOLOGICAL ANATOMY. with that form of degeneration known as hyaline fibroid degeneration, or arterio-capillary fibrosis. A marked hypertrophy and increase in number of those elements of the neuroglia, known as Deiters' cells, the lymph connective tissue of Bcvan Lewis, this being especially marked along the course of the blood-vessels. Degeneration of the nerve cell, the most common being the pigmentary or yellow globular form and consequent disappearance of nerve fibers in different parts of the brain. Spinal Cord. — The relationship between microscopic changes found in the cord and the prominence of spinal S3'mptoms is identical with the statement made on p. 250 in describing macroscopic appearances. The walls of the blood-vessels, especially those of the posterior columns, are thickened. The appearance, however, usually differs from that of the cerebral vessels, in that the lumen is diminished and the mus- cular coat hypertrophied. The lymph channels are not blocked up or dilated, and there is no nuclear proliferation. Bevan Lewis looks upon this change as " one of simple compensatory hypertrophy, induced by the engorged condition of these vessels demanding increased contraction on the part of the arterial muscle to carry on the circulation of the cord." The spider, or Deiters' cells also hypertrophy and multiply,^ the proliferation is most marked along the course of the blood-vessels. According to the tracts involved, as outlined in the description of the macroscopic changes on p. 251, the microscopic evidences of degeneration are found, i. e., loss or swelling of the myeline of the medullated fibers, or a granular condition of it with distortion and interruption of the nerve fibers. They * This hypertrophy is also found in chronic inflammatory and other disorders of the spinal cord. SPINAL CORD. 259 are usually most marked in the posterior columns, in some cases resembling in character and distribution the appearances found in tabes, in others the root zones escape. The question frequently arises concerning the rela- tionship between general paresis and tabes dorsalis. It seems safe to say that the opinion of most neuro- pathologists is that they are the same disease. As Dercum has expressed it, general paresis is a tabes of the brain. Mills also believes that they are the same process, in the one case affecting cerebral neurones mainly, in the other, spinal, while in a smaller group, both sets suffer and the clinical symptoms of general paresis and tabes are combined (see symptomatology). At a meeting of the London Pathological Society,^ at which most of the prominent English neurologists and neuro-pathologists were present, this subject was discussed. Mott, who opened the discussion, held that the two conditions are one and the same morbid process, affecting different parts of the nervous system. This view was concurred in by most of those present. Among those who hold similar views may be men- tioned Raymond, Flechsig and Nageotte; on the other hand Ballet, Joffroy, Geil and Hoche do not believe that the lesions are of the same nature. Besides the variations above described in the cord, we find in other cases both the lateral and posterior columns are affected, in the former the change is usually most marked in the dorso-lumbar region. Rarely degeneration may be found in the anterior columns, alwa3^s, however, in connection with dis- ease of either the posterior or lateral columns or both. Degeneration of the cells of the anterior horns is also usually more or less prominent.^ More or less ^Transactions London Pathological Society, 1900, 11, 339. ^Orr & Rows, Brain, 1901, p. 236. 26o PATHOLOGY AND PATHOLOGICAL ANATOMY. degeneration of the cells in the posterior root ganglia may also be found. The Peripheral Nerves. — Changes in these, both cranial and spinal are also found. Dr. Alfred W. Campbell ^ found extensive diseases of the pncumo- gastric and less extensive diseases of the phrenic nerves. More or less degeneration of the optic nerves may occur. The nerve libers of the anterior nerve roots are degenerated and the connective tissue is increased. These changes are usually most marked in the lumbar and sacral regions. The mixed spinal nerves also show evidences of degeneration. Campbell says this is a mixture of a parenchymatous degeneration (degeneration of the medullary sheath; swelling and atrophy of the axone), and interstitial inflammation (overgrowth of the con- nective tissue). These changes are most marked in the nerves forming the lumbar and sacral plexuses. The ganglia of the S3'mpathetic S3stem sometimes show evidences of degeneration of the nerve cells and increase of connective tissue. The muscles including the heart and diaphragm show degenerative changes, become fatt}', and show more or less complete disappearance of muscle fibers, with proliferations and increase of the nuclei of the sarcolemma and connective tissue. The number of motor end plates in the cases examined by Campbell was lessened and some were in process of degenera- tion. Pathology. — The starting point, whether in the blood-vessels or nerve elements, of the lesions above described, has caused much discussion and able ob- servers are ranged upon each side. One of the most ^ Journal of Mental Science, April, 1894. PATHOLOGY. 26 1 prominent and earnest advocates of the view that the primary seat of the lesions is the blood-vessels is Bevan Lewis.""^ He claims that there are three stages in the development of the morbid changes, viz: 1. A stage of inflammatory change in the tunica adventitia with excessive nuclear proliferation, pro- found changes in the vascular channels and trophic changes induced in the tissues around. 2. A stage of extraordinar}- development of the lymph-connective system of the brain, with a parallel degeneration and disappearance of nerve elements^ the axis-cylinders of which are denuded. 3. A stage of general fibrillation with shrinking, and extreme atroph}' of the parts involved. He believes that this is an irritative process of the arterioles of the pia and brain, but lays no stress on the changes in the walls of the capillaries. Berkley also advocates the view that the blood- vessels are the primary seat of the lesions. He says '} " While it cannot yet be regarded as an established fact that vascular disease precedes all cases of paretic dementia, this theory, while affording a ready means to account for the pathological etiology, would enable us to follow out the various steps in the clinical picture of the disease." "Thus, the first stage, that of mental change and irritability, would correspond to the inception of the vascular disease, slight proliferation of new elements in the sheaths, on account of which the nutrient serum finds some difficulty in finding its way through the thickened arteriole-capillary wall. The second stage, that of active delusion and motor excitement, would come when the nuclear proliferation, dilatation of the ^Mental Diseases, 2d ed., p, 552. * Italics author's. ^Mental Diseases, p. 202. 262 PATHOLOGY AND PATHOLOGICAL ANATOMY. lymph space, and filling up of the same with cells and cellular debris, would be sufficient to dam back into the brain tissue the devitalized serum, inducing both edema and cell hunger from the imperfect circu- lation of the necessary nutrient fluid. Many of the epileptiform and apoplectiform crises, no cause for which can be found in the naked-eye examination, might readily be due to the plugging of the perivas- cular lymph channel, either temporarily with leuco- cytes, or later permanently with proliferated round cells." " The final stage, that of dementia, would occur only when the arteries are profoundly diseased, and their surrounding canals completely obstructed by the cellular overgrowth and accumulation of debris from many sources. According to this view the degeneration of neurones and neuroglia play an entirel}^ secondary part, the cell atrophy and scler- oses of the tissue following the lesions of the blood- vessels." He further says (^loc. cit., p. 205): "That in the very earliest obtainable autopsies the protoplasmic alterations found are most indefinite in comparison with those in the vascular apparatus." He mentions a case that died at the beginning of the second stage, in which the vascular lesions were intense and the implication of both the vascular and support neuroglia was profound, but the investigation of the neurones gave practically negative results with modern methods. W. Ford Robertson ^ summarizes what appears to him to be the most probable hypothesis regarding the pathogenesis of general paresis as follows: "The disease depends upon the occurrence of a general toxic condition, the exact nature of which is still ' For an exhaustive discussion of both sides of the question with references, see Pathology of Mental Diseases by W. Ford Robertson, p. 344 et seq. Fig. I. — Normal capillaries of human cerebral cortex. Bevan Lewis's fresh method. X 500. (Clouston.) Fig. 2.— Capillaries of cerebral cortex from a case of advanced general paresis, showing marked thickening and granularity, and increase in number of nuclei. Bevan Lewis's fresh method. X 300. (Clouston.) Fig. 3.— Greatlv hypertrophied neuroglia cells, surrounding an arteriole in the deepest laver of the cortex, in a case of advanced general paresis. Aniline black fresh method. (■; 500.) The arteriole shows periarteritis. The nerve-cells have for the most part disappeared. Those that remain show advanced pigmentary degeneration. (Ford Robertson.) Fig. 4.— Normal nerve-cell, showing the chromophile elements of the protoplasm and the cone of origin of the axis-cylinder process. (Ford Robertson.) Fig. 5.— Three cortical nerve-cells from a case of advanced general paresis, showing slow degenerative changes of primary type; a. cell with large pigmentary accumulation in the protoplasm and pallor and slight disintegration of the chromophile bodies; />, advanced chromatolysis ; r, advanced chromato- lysis, loss of processes and commencing disintegration of the nucleus. (Ford Robertson.) PUie XIIL * *9f I. If' **// ■i^ r PATHOLOGY. 263 obscure, but which is certainly in many cases the result of antecedent syphilitic infection. The first important effect produced by the toxins is a prolifer- ative and degenerative change in the walls of the vessels of the central nervous system, including those of the capillaries of the cerebral cortex. This alter- ation in the capillary walls interferes in various ways with the nutritive exchanges between the blood and the cerebral tissues. Consequently the adjacent cor- tical neurones undergo primary degeneration and the neuroglia also tends to suffer certain morbid alter- ations. At the same time these tissues are to some extent affected directly by the toxic agents circulating with the blood." He places special stress upon the influence of the changes found in the capillaries and is a strong believer that these vascular lesions are due to a toxic condition. This view first advocated by Angiolella is held by many, even the majority of those who do not believe that the blood-vessels are first attacked, believe that "general paresis is due to toxins, the result of auto-intoxication from previ- ous infection of the system by syphilis or other poisons." Among the advocates, which are many, of the view that the neurone suffers primarily may be prominently mentioned Nissl, Tuczek and F. W. Mott, the'latter has recently in a number of papers supported this theory.^ He believes it to be " like tabes a primary degeneration of the neurone, with meningo-encephalitis that is secondary." This is due, he thinks, to a premature failure of the specific vital energy of the neurone. In this view of the cause, he differs from some of the other advocates of this theory, who believe that the 1 Archives of Neurology, 1889, Vol. i, p. 7 ; ibid., p. 166. Brit. Med. Jour., Nov. 25, 1899; /(&/(/., June 23, 1900. Trans. London Path. Soc, 1900, II, p. 339. 264 PATHOLOGY AND PATHOLOGICAL ANATOMY. degeneration of the neurone is due to the intiuenee of a toxic principle of some sort. With such eminent advocates of both views it does not seem advisable in a work such as this to advance any dogmatic opinion. The references given will enable any who desire to study the matter for himself. It seems safe to say, however, that whether the primary seat of the lesion is in the blood-vessel or in the neurone, that the cause is a toxic principle, the nature of which is not understood, but is probably in most cases, at least, the outcome of a previous syphilitic infection. In this connection should be mentioned the recently ex- pressed views of W. Ford Robertson and Lewis C. Bruce ^ that general paresis is due to a toxemia of gastro-intestinal origin, due to overgrowth of the bac- teria that normall}' dwell in the alimentary tract, and that S3'philis acts as a predisposing cause by altering the normal immunity. This, while not yet confirmed by others, is novel and interesting. The Viscera. — In respect to the condition of the body and viscera of patients dying of general paresis it has been found by comparison that the patholog- ical records of the Government Hospital for the In- sane, Washington, D. C, and the State Hospital, Norristown, Pa., institutions where the writer for- merly served, conform very closely to the published results of Mickle, derived from a large series of post- mortem examinations. Hence, as confirmatory of ample experience, an abstract of these results may be given: Body-nutrition. — In about one half of the cases the nutrition of the body was fair or good ; in nearly fifty per cent, there was some degree of emaciation, of 1 British Medical Journal, June 29, 1901. LIVER. 265 whom one half at least may be said to have shown extreme emaciation. Only a relatively insignificant number, less than three per cent., were very fat. Heart. — Pericardial fluid was somewhat increased in one third of the cases. Blood: usually, the right chambers of the heart were full, the left ventricle nearly empty. The cardiac clots were softish, oc- casionally firm, rarely was the blood entirely fluid. The heart-muscle was more or less softened and un- duly flabby, or friable in about two thirds of the cases. One or both of the valves of the left side of the heart were altered in at least two fifths; increased thick- ness, opacity, atheromatous and calcareous changes were by far the most frequent; but vegetations, cohesions, valvular obstruction or incompetency were occasionally seen. In two per cent, there was marked dilatation of the heart and in eight per cent, marked hypertrophy. In about half of the cases, one or both of the coronary arteries, especially the left, were found to be more or less atheromatous. Lungs. — Old pleuritic adhesions or pleuritic thick- enings were noted in two thirds; hypostatic conges- tion, or marked congestion and edema of bases, in more than two thirds ; and some serous fluid in pleura in nearly half of the cases. In one third of the autop- sies there was more or less pulmonary tuberculosis, occasionally there was ordinary caseous (catarrhal) phthisis. In one third, marked hypostatic pneumonia and in one fourth of the cases there was a form of lobular pneumonia; both, occasionally, were found with or passing into slight local gangrene. Liver. — In about half of the cases there was marked passive congestion of the hepatic veins; and in one sixth of these the appearance was distinctly " nut- 266 PATHOLOGY AND PATHOLOGICAL ANATOMY. meggy." The hepatic substance was unduly friable, or flabby in eleven per cent., merely too firm in six per cent, and in eleven per cent, it was slightly cir- rhotic. In a small per cent, of the cases the liver- capsule was thickened and in about the same number there were old perihepatitic adhesions to neighboring parts. Spleen. — In nearl}^ one half, the spleen was de- cidedly too firm; in a small per cent, unduly soft. In a few cases its capsule was extremcl}- pigmented and in an equal number the spleen was unusually notched. Kidneys. — In nearly one half of the cases some marked morbific change in the kidneys was found. In eighteen per cent, the kidneys were noted as being markedly cirrhotic, or atrophied and granular; in thirty-four per cent, the capsules were adherent; and in twelve per cent, there was discovered the ordinary cystic change. The kidne} s were found congested in eighteen per cent. In two to four per cent, the following conditions were recorded: Marked lobula- tion; extremely thickened capsules; fatty kidney; induration (independent of " granular " change) ; locally cicatrized surface; old perirenal adhesions; horseshoe kidney, and renal calculus. CHAPTER XVIII. TREATMENT. I. Prophylactic Treatment. {a) Hereditary Pre- disposition. — Prophylactic treatment, without doubt, would be the most important division of treatment, if it could be made effective, because it reaches not one life alone but many. The first consideration, then, in the treatment of general paresis, is the eradication of any tendency towards hereditary predisposition. While general paresis is not so largely a hereditary disease as some of the other forms of insanit}^, yet even here the fruits of a weakened nervous constitu- tion tell on the next generation with no abatement of force. We find that in a large number of paretics the brain is defective from birth, so that while the parents for the most part have not been subjects of the disease, paresis in the oflfspring has resulted from a vitiated state of the brain, entailed by other neuropathic con- ditions in the parents. Profiting by the general knowledge in the preven- tion of hereditary diseases, many of the ills of life could be escaped, if medical men in general practice, with courage equal to their convictions, would assert the dangers of the neuropathic predisposition. The physician is, and must be, the conservator of the pub- lic health and, looking to the welfare of posterity, he should use his influence to the utmost to root out any preventable tendency to weakness and disease in the race. Clearly it should be his duty to impress strongly on the minds of his patients the necessity of the avoidance of the marriage of neuropathic people. 267 268 TREATMENT. With less forethought than the breeders of cattle, we never raise our voice against the " sowing of tares," in the pernicious habit of indiscriminate marriage of the " unfit." Never has there been a time when the teachings of the medical profession have claimed more attention than to-day. This condition is laro-elv due to an intelligent public, who by their wide general reading and consequent application of scientific truths, are ready to heed the warnings thus pointed out, which a generation or two ago would have fallen on deaf ears. This state of affairs is the good soil on which the family physician should not neglect to scatter his seed of good advice most faithfulh'. It is only by the development of a healthy public sentiment that such good can be accomplished, for laws will never be enforced unless in harmony with the ideas of the communit}'. Hence legislative action should follow, not precede, public sentiment. Later, cautious legis- lation can cr3'stallize the sentiments developed in a community by the concerted action of thousands of physicians. (/?) Individual Predisposition. — A more active field promising more immediate results, is the removal of individual predisposition. The children already endangered by a vicious heredity should be given, so far as possible, a balance against the onset of disease. The earlier this is established the better; herein lies one of the oppor- tunities of the physician. He may do much towards securing for the individual a healthy body, if he insists that self-control, freedom from excitement and over-tire be maintained; that a healthful moral and intellectual training shall be given; and that well- balanced mental powers be developed with broad- minded judicious habits of considering religious, TREATMENT OF THE ESTABLISHED DISEASE. 269 social, and intellectual subjects. The energies should be directed into proper channels and later the lesson be taught that strain of worry or excess of any kind is poison to mind and body. In many cases should be emphasized the dangers from the over-strain and over-living of the twentieth century civilization, resulting not only in paresis, but in the many forms of neuropathic heritage. Thus the physician should enlighten and warn; and b}' every prophylactic means in his power strive to ward off the encroachment of this dire scourge of modern times. (c) The Tlireatejied Attack. — A still broader field of prophylactic treatment is the actual prevention of an impending attack of general paresis by removing the patient from the circumstances or environment under which premonitory symptoms have been ob- served and reo;ulatinor the life so that such an attack is lessened or removed. This means the regulating of every movement of the patient, the removal of all strain or excess, the use of regular bodily exercise, early hours for retiring, massage and bathing, the gentle use of the intellectual and moral faculties, the avoidance of wines, tobacco and coition. It is abso- lutely essential to cut the patient otf from severe work and anxiety and yet judgment must be used. It may require a determined effort on the part of the physi- cian bu^ he should not be disheartened or rebufted by the patient's environment but gently and firmly force him into other life. It is not necessar}' to do this hurriedly or ill-advisedly but by degrees the patient can be made to do things that misfht be deemed absurd or impossible if forced upon him m an mjudi- cious manner. 2. Treatment of the Established Disease. — The very early stage of the disease is the one that presents op- 24 270 TREATMENT. portunities most favorable for treatment, and the only period in which hope of permanent relief can be as yet entertained. The care of general paresis, nat- urally, divides itself into the hygienic management of the case, as separate from the strictly medical treat- ment. As the former life of the paretic is, in a large de- gree, responsible for his breakdown, the causes that have brought on him his misfortune must be closely studied and the axe laid at the root of the tree. By attention to healthful means the general tone of the system can be built up, and by a judicious regulation of the habits and life of the patient much can be done, at this time, to check the impending tendencies of the malady. The stress of the environment, or of busi- ness strain, if ever relieved to the benefit of the patient, can best be accomplished at this period, if the friends are tactful in their intiucnce. In some cases the patient may even be informed of the gravity of the results, if he persists in his course of worr}' or excess, and if he be at all in a condition to be swayed by wise motives, he may be brought to a realizing sense of the folly of his ways. If at this stage, freedom from mental anxiety, change of scene, and a personal interest in other less absorb- ing surroundings, can be secured, together with hygienic conditions of living, there is fair prospect that healthy cerebral activity may be restored and sufficient force acquired to thwart the advance of the morbific processes. One author says: "More or less complete arrest of the disease may be favored by the recognition of its early stage, and by treatment which practically amounts to putting the brain in a splint, as it were." Voisin in France and Meynert, among the Germans, have expressed a confident belief that paresis is susceptible of cure in its earl}- stage. Mey- TREATMENT OF THE ESTABLISHED DISEASE. 27 1 nert based his belief on the theory that preceding and causing the diffuse cortical encephalitis, there is a functional vaso-motor disorder, which he considered curable. The means here to be pursued are much the same as those which are employed as prophylactic meas- ures. It implies a careful oversight and control of the details of the patient's living; work, both mental and physical, reduced; the removal of all stress and strain; abstemious habits of living, such as the avoid- ance of wines, tobacco and coition; the use of mild bodily exercise, early hours and watchful care of sleep; a suitable diet and very careful attention to the state of the bowels; the application of massage and a systematic course of hydrotherapy, combined with the partial " rest cure." In certain cases elec- tricity in some of its forms will be found of advantage. The physician must not yield to any discouraging ex- igencies in the patient's surroundings, but gently and firml}', by the influences at his command, direct the life of the patient into more wholesome channels. If there is impaired health the bodil}' functions should receive attention, the general condition built up, with tonics if necessary, and such plan of treat- ment instituted for this end, as best meets the views of the individual practitioner. But rest, fresh air, wholesome food, moderate exercise and regular hours will be found to be, as ever, the greatest restorers of energy. Even in suspected cases, where the diagnosis has not been fully made out, it is well to advise rest; and in most cases removal from the daily occupation and surroundings. At this time the question of travel will force itself on the attention of the physician. The word " travel " is attractive to the mind of the over- worked practitioner and patient; in truth, it has a 272 TREATMENT. sweet sound to most cars. But it is now generally recognized that travelling of any kind is conducive to more harm than good to a paretic patient, attended with its hurr}', anno3'ance and excitement. There can be no doubt that a change of environment will always be of benefit; but the special form of the change must be left to the discretion of the advisors, in each individual case, which must be decided in accordance with the circumstances. Danger from suicide, or assault, may have to be guarded against, and the very prevalent risk of dissipation of property should be ever kept in view. If the removal from home, in the early stage, should involve the loss 01 income, or be a serious interference in business, so that the anxiet}' resulting would be of greater injury to the patient, then a lightening of labor alone may be insisted on, together with the adjustment of the home life. The subject of food needs further elucidation. In the first stage, when there is much excitement, the diet should be light and easily digestible, and abso- lutely prohibitory of alcohol in any form. It will be difficult to insure temperate eating and drinking, for the appetite, always large, is frequently so voracious that nothing short of over-repletion will satisfy the patient's desire. In the later stages the nourishment should be more generous. Milk and eggs may be placed at the head of the list. These articles of diet can be prepared in many ways, so as to prove tempt- ing dainties to the sick. Vegetables, celery, aspara- gus tops, and fruit should be freel}' allowed. Meats on the other hand should be restricted. Owing to paresis of the muscles of deglutition much care must be exercised that the patient does not choke, or that food is not introduced into the trachea. By easy gradations the food administered must pass from solid GENERAL MEDICAL TREATMENT. 273 to minced and from that to liquid form, in the last months of his life. Alcohol, which at first is with- held, may be given with benefit in the third, or last, stage. As stated under etiology, there is at present a strong trend in the belief among psychiatrists towards the theory that general paresis is an affection due to chronic toxemia. There are indications also that the poison is of bacterial origin through the digestive system. These observers uniformly teach, whether they believe the primary process to be nervous or vas- cular, that the natural immunity of the gastro-intes- tinal tract is modified by the breaking down of those forces which control normal metabolism. The light that recent phj'siological chemistry and bacteriology has brought to the solution of this problem may soon mark the pathway to remedial measures, such as specific serums or other antitoxins, that will neutralize the influence of these poisons which gain access to the circulation. If this hypothesis should be confirmed it is not improbable that this malady, thus far fatal, may be transferred in a few years to the list of curable diseases. General Medical Treatment. — As yet there is no spe- cific drug or class of drugs which can be regarded as at all remedial in character. This should not be a cause for discouragement, however, for much may be done to alleviate the various conditions and to retard the progress of the disease. It is necessary to bear in mind always that the most unaccountable remis- sions may appear from time to time, even in the final stages, so that the physician's efforts should not be relaxed, or his prognosis, as to the immediate results, be too gloomy. The plan of treatment suggested in the prodromic period should be continued and it is 2 74 TREATMENT. well to remember that in an affection which promises so little from the use of drugs the hygienic and mental management of the case, together with effi- cient nursing, hold the chief place in the treatment. In making a review of the therapeutic history of general paresis, one becomes clearly convinced of what a mightv struggle there has been waged against this formidable disease. It would seem that there is scarcelv anv drug or remedial measure, at all applic- able, that has not been brought to bear against it. Counter-irritation, derivation, revulsion by blisters, suppurants, cauteries, or setons to the neck, spine or scalp; venesection^ and leeching; and repeated paintings with iodin have been faithfully applied but should be rejected as too severe and of doubtful utility. Veratrum viride, tartar emetic and diuretics; nitrate of silver, zinc, physostigma, papaverine and apomor- phia, have had their adherents in the past, but are seldom resorted to at the present day. We mention them in order to call attention to the fact that, now and then, some good has resulted from the use of them. Tonics. — In manv cases, in the early stages that are free from excitement, there are indications for the use of tonics, and most cases call for this plan some time during the course of the disease, especially if the patient be enfeebled, emaciated, exhausted or phthisical. They should not be given indiscrimi- nately, much skill can be displayed in the choice of them, which must be left in great measure to the judgment of the attending physician. Among the most prominent may be mentioned the preparations of iron, the vegetable tonics, cod-liver oil, the hy- * A man who had decided to commit suicide by letting his blood, felt so much better after considerable blood had escaped, that he had the wound bound up again. Also a gentleman greatly depressed in mind who was being bled : as the blood tlowed, he gradually changed and tinally began to joke, etc. (Abstract, Sankey, op. cit., p. 311.) GENERAL MEDICAL TREATMENT. 275 pophosphites, quinine, strychnia, arsenic and phos- phorus. The number of elegant pharmaceutical for- mulas containing these in various combinations in the market is legion. Sedatives, — There is a long list of drugs of this class, which would carry us into too great prolixity to discuss separately. The selection or combination used is susceptible of a widely varying discriminat- ing choice. The chief ones are: Opium, morphine, bromides, chloral, cannabis indica, veratrine, hyos- cyamin, hyoscine, duboisin, sulphonal, trional, hypnal, tetranal, paraldehyde, chloralamide, antipyrin and chloretone. Ergot,, Ergotin. — Ergot or ergotin has enjoyed some reputation, when administered continually for a long time, in moderate doses, in relieving the cere- bral congestion, underlying excitement, and in ward- ing off congestive seizures, but its value has not been uniformly apparent and it has fallen into general disuse. Digitalis,^ Digitalin. — Digitalis has been em- plo3^ed by French and English physicians, to combat maniacal excitement, and the tendency to cerebral congestion, with fairly good results, but there are drawbacks and dangers to its use that seem to check enthusiasm. AntisypJiilitic Remedies. — The observations of Collins,^ under antisyphilitic treatment in tabes, equally apply to the advisability of antisyphilitic treatment in paresis. When syphilis is the causative factor neuro-alienists are not agreed as to the impor- tance of specific treatment. Some, following Charcot, steadfastly hold that such treatment is useless, no matter how indifterently the patient may have been treated during the active period of the S3'philitic poi- 1 Treatment of Nervous Diseases, p. 233. 276 TREATMENT. son, providing that the symptom-complex of paresis did not develop within a short time after the syphilitic infection, from two to four years, when the lesion ma}' be properly considered a true S3'philitic and not a parasyphilitic one. On the contrary, others, following Erb, recommend an active course of antisyphilitic medication in'cvery case of paresis with a history of S3'philis, or even upon the suspicion of a taint, or where this method will speedily clear up any confusion with cerebral svphilis. Berkley ^ inaugurates, at once, inunctions of blue oint- ment, or oleate of mercury, or the hypodermic admin- istration of the bichloride, or the sozoiodolate of mer- cury in salt solution. While his preference is for the mercurial salts, he uses, also, the iodide of potassium in doses gradually increasing to sixty grains or up- wards, thrice daily. In these cases. Osier ~ pre- scribes large doses of the iodide of potassium. Collins believes that the best results can be obtained by the use of mercury by inunction; if this method cannot be carried out then its use h3'podermatically. Mer- cur}', as specific means, he believes should be given in no half-hearted way. He is accustomed to use from thirt}' to fort}' grains of blue ointment rubbed in daily, each application lasting from twenty to thirty minutes and the course continued from five to six weeks. He cautions watchfulness over the condition of the patient's alimentary tract, skin and body weight. Too much care cannot be taken to keep him clean, much in the open air and well fed. Great importance is attached to the maintenance of the body weight; if this cannot be done the mercury should be stopped at once. After the mercury treatment has been sus- pended, the patient should receive a vigorous tonic plan of treatment for several months. 1 Mental Diseases, p. 195. ^Practice of Medicine, 3d ed.. p. 964. GENERAL MEDICAL TREATMENT. 277 The author agrees with Collins that nothino- is to be expected from the administration of mercury, be it by the mouth, inunctions, or h3'podermatically, in cases of genuine paresis in which no syphilitic mani- festations are present but that harm even may arise from such a course. On the other hand, iodide of potassium, given in small doses and for a long time, especially in conjunction with measures that improve the nutrition and husband the energy, is one of the most valuable drugs to delay the decay of the pri- mary neuron. Electricity. — Either static, constant or induced, in the hand of some practitioners, who are skilled in its application, is highly extolled, especially in the pro- dromal stage. Combined as it is apt to be with mas- sage and other devises employed in asthenic nervous conditions it has often been attended with good re- sults. The head and spine are the regions to be treated. Hydrothei'apy. — Douches, the warm bath with cold to the head, wet pack and other forms of application of water cure have been very useful in the hands of many in the treatment of the initial period; and, also, in the later stag-es this form of treatment has at times brought about marked amelioration of the symptoms. In the Government HospitaP at Washington, as an in- stance, this plan of treatment was instituted a few years ago and the physicians speak most enthusias- tically of the results. For details in the application of electricity, hydrotherapy, massage and rest treatment the student is referred to the well-known works on nervous diseases. Tre-phining. — Although of occasional value, surgi- cal measures have proved unsatistactory. Trephining has been practiced chiefly, over the parietal region, ' Forty-first Annual Report, p. 160. 30 278 TREATMENT. both in this country and abroad. The operation was originally proposed on the supposition that in paresis there was present an increased intracranial pressure. Treatment of Special Symptoms. — In the treatment of the special symptoms the same general principles must be adopted that are found to be efficacious in the relief of the same symptoms, in other forms of mental disease. ]\fe?ital Excitetneui. — Sankey recommends the combination of digitalis and opium, as advised by M. Dumesnil. He gives it in the proportion of one drachm of the tincture of opium (Br.) to ten minims of the tincture of digitalis, every four hours, until the patient becomes more tranquil or sleeps. Peterson resorts to hyoscin, hyoscyamin, or duboisin (gr. yj^r to gr. yV)) hypodermically, in periods of maniacal excitement. Dercum speaks highly of antipyrine (gr. X to gr. xx), every four hours. The bromides, chloral, sulphonal and trional, by others, are given separately or combined, and paraldeh3de for the same purpose, to induce quiet and sleep. The use of the hot bath, with cold to the head, followed by isola- tion, are good tranquilizing agents, as well as the wet pack. Insomnia. — In the earlier stages of paresis, the patient often suffers acutely from sleeplessness, which serves to aggravate the other nervous symptoms. The remedies suggested in the period of mental ex- citement may all be of service in insomnia. Paralde- hyde, in doses of twenty to thirty minims, may be given at bed time, or double this amount suspended in thin mucilage, administered by the bowel. As Stearns has said, there is less objection by paretics to this drug, on account of taste, than by other classes of invalids. Some alienists keep to the use of chloral TREATMENT OF SPECIAL SYMPTOMS. 279 In preference to the newer remedies. A combination of equal parts of trional and sulphonal answers well as a hypnotic in many instances. The rapidly induced effects of the former are supplemented by the less transient action of the latter drug. These two last- named drugs are not very poisonous in single over- dose, but there is a variety of chronic poisoning by them that may be even more serious, brought about by too long duration of their use. The symptoms are an obstinate constipation, diminished quantity of urine and hematoporphyrinuria. If treatment be prolonged, one should be on his guard for the toxic symptoms. Constipation of marked obstinacy with scanty dark red urine, should at once excite suspicion. Chloretone has not passed the stage of experimenta- tion, but already its unfavorable record as a depres- sant of the heart raises a danger signal to its pro- miscuous use. Epile-ptiform Seizures. — Many agencies have been sugsested for the relief of these attacks. Setons and vesicants to the nape of the neck, painting the neck with iodine, and trephining have accomplished but little. The continuous use of the bromides for long periods of time is, perhaps, the best treatment to ward off threatened attacks, giving attention, in the mean- time, to the general condition of the patient. In status epilepticus, rectal injections of chloral in starch water are recommended. The seizures may be so marked as to require the inhalation of chloroform. The bowels and bladder should be evacuated, the lower bowel by enemata. A drop of croton oil on the tongue, if other purgatives cannot be given, may relieve the cerebral congestion by purgation. Apoplectiform Seizures. — In this condition the requirements are, the elevation of the head, the use of free purgation, the application of cold to the 28o TREATMENT. head, with or without a prolonged warm bath. The alkaline bromides and ergot are recommended in full doses. In suitable cases, when the cerebral congestion is marked, leeching, blood-letting by venesection or cup, calomel, digitalis, camphor enemata have all been used. Hot mustard foot baths seem frequently to arrest an attack. Bed-sores. — In the last stages of paresis much care must be taken to prevent the forming of bed-sores. Perfect cleanliness should be enforced; the use of a water bed, with frequent changes of position, and with buffers of some soft antiseptic material over the bony protuberances, is indicated. The skin may be hardened by white of egg and spirits, or by a strong solution of tannin, or a strong solution of sulphate of zinc. If sores form, despite every precaution, they should be carefully treated and watched. Many of these sores are really trophic in character and not due to pressure at all. This is shown by the fact that they appear at points where no pressure has been exerted. Hughes recommends a novel plan of treatment. He orders the sore washed with warm water and castile soap, and then thoroughly rinsed. A liquid preparation of beef bovinine is poured over the sur- face of the ulcer and the surface is saturated by using pledgets of lint. The ulcer is carefully covered, as in a surgical dressing. Granulations appear gradually after this treatment, followed by an epithelial cover- ing. This treatment is effective, for the tissue thus formed is not less resistant than the neighboring skin. Terminal Symptoms. — Life in the open air is ad- visable, as long as it can be continued; as soon as the patient is not able to walk alone he should be given assistance; when this assistance no longer avails, a reclining chair should be used, and thence by stages, TREATMENT OF SPECIAL SYMPTOMS. 201 he must go to the constant use of an air or water bed. At this period an abundant and nourishing diet should be used, but it must be administered with care; the paretic is apt to bolt his food and hence is frequently in danger of choking. There is danger, too, of the inhalation of food and of resulting lobular pneumonia. In cases of dysphagia it may be neces- sary to use the nasal tube in giving food; in these, and in very demented patients, it is sometimes im- perative, for brief periods, to administer peptonized food by the rectum. Perfect hygiene is of the utmostjmportance. Reg- ular bathing must be continued and a constant vigilance for bed-sores be maintained. At this stage when the sphincters are paralyzed, or at best react sluggishly, cleanliness is difficult to secure but is absolutely necessary. Excreta should be removed promptly and every precaution taken to keep the skin free from irritation. The bowels must be kept open and often comparative regularity of action can be secured by using, at stated times, a simple enema. Gentle massage also may be used to secure regularity of the bowels. In cases of diarrhea, often troublesome in the last stages of paresis, the matter of cleanliness becomes a great tax, but it must be maintained with most as- siduous care, and the diarrhea must be given the usual treatment. Catheterization should be avoided, as long as it is possible to produce urination by other means. The patient must be encouraged to evacuate his bladder by his own efforts, and to complete the evacuation, gentle^ manual pressure may be used; unless this is done the decomposition of the residual urine quickly sets up cystitis. ^ Be sure the pressure is gentle, for too great force may result in rupture of the bladder. 282 TREATMENT. By such constant and faithful care, the life of the patient may continue for months, in a weak and bed- ridden, but still comparatively painless condition. INDEX. A BSCESS, 66, 150, 233, 23s ^ Acute mania with delusions, 17S Agapoff, 256 Age of occurrence, 204 Amenorrhea, 33 Amnesia, 27-29, 30, 35, 110 Analgesia of ulnar nerve, 146 Anesthesia, local, 33, 62 Angiolella, 214, 263, 283 Anglade, 193 Anglo-Saxons, paresis in, 210 Anxiety as a cause, 221 Antisjphilitic remedies, 275 Aphasia, 117, 118 Aphonia, 119, 132, 146 Apoplectiform seizures, treatment of, 279 attacks, 34, 58, 129 Apoplexy, 177 Appetite, voracious, 55 Argyll-Robertson pupil, 93, 125, 139, 1^8 Arson, act of, iii Arthropathy of knee joints, 151 Articulation, impaired, 33, 45, 56, 65, 117 Atrophy, optic, 26, 96, 139, 140, 141, 195 prog, muscular, 150 Auto-intoxication, 214, 263, 273 DAILLARGER, 20, 75, 76 ^ Baker, J., 11 1 Bacterial infection, 214, 263, 273 Ball, 21 Ballet, 32, 259 Bannister, 193, 204 Bayle, 19, 41 Bed-sores, 65, 72, 100, 150, 157, 241 treatment of, 280 Bell, Luther, 21 Berkley, 35, 62, 80, iii, 112, 188, 193, 248, 261 Bettencourt-Rodrigues, 124 Bianchi, 124 Bigamy, 40 Bladder, rupture, 281 trouble in paresis, 169 Blandford, 35, 77, 82, 88, 181, 233, 237- 239, 240 Blood changes in, 151, 164 sweating, 147 -vessels of brain, pathology of, 252 Body nutrition, 264 Bones, 158, 160 Bonnet, 193 Brain, pathology of, 246 macroscopic, 246 microscopic, 251 in acute cases, 247 in chronic cases, 248 Briscoe, 239 Bronchitis, 86 Brush, 238 Bucknill, 50, 57 Bucknill & Tuke, 50, 215, 217, 232, 233 Burr, C. B., 158, 160, 236 pALMEIL, 19, 22, 75 ^ Campbell, Alfred, 260 Clark, 34, 38, 43, 72, 78, 85, 92, 96, 115, 132, 135, 198 Catheterization, 281 Carbuncles, 233 Causes, 17, 1S7 (see Etiology) Cephalalgia, 175 Cerebellum, pathology of, 249 Cerebral seizures, 58,64, 127,129,171 Chapin, 187 Character, change of, 28, 31, 34 Charcot, 93, 105, 192, 275 Children of paretics, 189 Christian, 128, 218 Chorea'and paresis, 228 Chronic alcoholic insanity, 173 283 284 INDEX. Circular form, 82 typical cases of (Blandford), 82 { Campbell-Clark ) , 84 (Magnan), S3 (Savage), 83 Classes, higher and lower, 211 Classification of varieties, 73 Climacteric, influence of, 106 Clouston, 24, 47, 53, 61, 67, 85, 86, 90, 95, 97, 124, 134, 136, 140, 146, 147, 158, 161, 189, 218, 224, 237, 248 Collins, 275 Commencement, mode of, 22 Congestion of optic discs, 142 Congestive attacks, 58, 67 Conjugal general paresis, 107 Contractures, 26, 65, 69, 72, 100, 102, 107, 139, 197, 214 Cortex, pathology of, 248 Cranium, pathology of, 246 Curability, probable future, 273 Cystitis, chronic, 167 nAWSON, 142, 148 ^ Deafness, 143, 146, 217 Decortication, 247, 250 Defects of speech, 33, 45, 57,65, 117 Definition of paresis, 22 Deglutition, impaired, 66, 67, 90 Delaye, 17, 19 Delusions of grandeur, 25, 38, 41, 47, 49, 50, 59, 62, 68, 70, 71, 207, 227" of persecution, 83, 142 Dementia, simple progressive, 94 Dercum. 60, 194, 213, 215, 237, 259 Developmental paresis, 93, 97-106 De Boismont, 30 Diet, 272 Deiters' cells, 253 Differential diagnosis, 172 acute mania with delusions, 178 apoplexy, 177 chronic alcoholic insanity, 173 disseminated sclerosis, 180 epilepsy, 177 lead poison, 180 paralysis agitans, 181 paralytic insanity, 175 senile insanity, 179 syphilitic insanity, 174 Diagnosis, tabes dorsalis, iSo typical cases of diagnosis( Bland- ford), 181 (F'olsom), 182, 185 (Tomlinson), 183 Digestive disorders, 33 Discovery, date of, 18 Disseminated sclerosis, 180 Double for in, 82 Doutrcbcnte, 18S Down, 91 Dvial theory of paresis, 17, 20 Dunn, E. L., 102 Dura, pathology of, 246 Duration, 236 typical cases (Brush and Sink- ler),238 (Blandford), 239 (Briscoe I, 239 (Fisher, E.D.), 237 (Journal of Mental Science), 239 (Lapointe), 238 Dysmenorrhea, 33 PARLY life, paresis in, 93, 97-106 ^'' Edema of lungs, 241 Electricity, 277 Emaciation, 64, 66, 70, 72, loo, 265 Embolism, 242 Epilepsy, 177, 21S Epileptiform attacks, 34, 40, 58, 62, 70, 72,83,96,95, 133, 196, 200 treatment of, 279 Erb, 276 Erysipelas, 233, 242 Esquirol, 19 Etiology, 1S7 age, 204 typical cases (Savage), 206 (Tomlinson ), 306 epilepsy, 218 typical cases of (Chris- tian I, 218 (Sankey), 219 (Workman), 218 excesses, 212 heredity, 187 typical cases of (Charcot), 191 (Clouston & Sav- age), 189 (Grannelli), 193 (Hotchkis), 190 INDEX. 285 Etiology, heredity, typical cases of (Mott), 191 (Muller), 192 (Revue de Psy- chologie), 190 (Wilson, G. R.), 189, 190 injury to the head, 214 theory of Dercum, 215 typical cases of (Bucknill &Tuke), 215, 217 (Clouston), 217 (Mickle), 216 (Neff), 216 (Rayner), 215 (Sankey), 216 intellectual overwork, 221 typical cases of (Sankey), 222, 223 (Savage), 221 physical overwork and strain, 220 race and social influences, 209 table by Spitzka, 210 typical case (Work- man), 212 sex, 201 ratio of liability, 201 table by Regis, 201 typical cases (Bannister), 204 (Marr), 204 (Middlemass), 202 (Sankey), 203 syphilis, 193 statistics, by Bannister, 193 by Berkley, 193 by Graf, 193 by Houghberg, 193 by Kraepelin, 193 by Lewis, 193 hy Mendel, 193 by Peterson, 193 typical cases of (Campbell Clark), 19S (Folsom), 198 (Norman), 195, 199 (Savage), 195, 197 (Von Rad), 197 temperament, 200 typical case (Savage), 102 toxic agents, 214 theory of Angiolella, 21^ typical cases (Stearns), 213 (Wiglesworth), 214 Exaltation, 30, 31, 35, 42, 50, 52, 53> 62 Exhaustion, 64 Exposure to cold causing paresis, 220 Excesses, 212 Eye symptoms, 137 'CACIA.L expression, 46, 57, 60, 96, -•■ 116, 200 Farrar, Reginald, 17 Fatigue, early, 34 Finnegan, 142 First stage (second period), 41 mental symptoms of, 41 hypochondriacal, 43 maniacal excitement, 43 melancholia, 43 physical symptoms of, 44 defects of speech, 45 facial expression, 46 pupillary anomalies, 45 tremor, 45, 46 tjpical cases of (Bucknill and Tuke), So (Clouston), 47, 53 (Fox), 48 ( Hammond) , 50, 54 (Sankey), 49 Fisher, E. D., 37, 96, 23S Flechsig, 259 Food, 272, 2S1 Folsom, 34, 36, 37, 40, 73, 79, 108, 109, 1S2, 183, 1S5, 188, 19S Fournier, 194 Foville, 162 Fox, 48, 155 Fracture of bones, 159, 160 Froelich, 161 pAIT, 40, 46, 48, 58, 61, 65, 66, Si, ^ 103, 120, 127, 143 Galloping form, 80 Gangrene of lip, 155 Gastric crisis, 33, 85 Geil, 259 General paresis following ordinary insanity, 79) 224 following paranoia, 79 j Georget, 19 Germans, paresis in, 210 Giannone, 146 Grannelli, 193 Gray matter, pathology of, 249 Griesinger, 34 286 INDEX. Giiislain, 214 Gun, tiring of, exciting cause, 217 TJALLUCINATIONS, 72, 85, 90, •^1 114. 131, 217 Hair, 150 Hammond, 29, 40, 50, 54, 63 Handwriting, 1 19 Haslam, 18 Headache, 33, 34, 128 Hebrews, paresis in, 210 Heart, pathology of, 265 Hematoma auris, 161, 195 Hemiplegia, 38, 72, 95, 133, 209 Heredity, 82, 106, 187, 267 Higher and lower classes, 2H Hirschl, 205 History of paresis, iS Hoch, Aug., 104 Hoche, 259 Hoestermann, 79 Homicidal impulse, 43, 61, 198, 20S Hotchkis, 190 Houghberg, 194 Hughes, D. E., 79, 280 Hurd, H. M., 33, 233 Hydrotherapy, 271, 277 Hypochondria, 43, 61 Hypothetical case in prodromal stage (Sankey), 24 Hysteroid attacks, 129 INJURY to the head, 214 ^ " Insane ear," 161 Incontinence of urine, 169 Insomnia, 32, 47, 90, 145 treatment of, 278 Intellectual overwork, 221 Irish, paresis in, 210 Irritability, a symptom, 30, 34, 37-39, 43.61 TELLIFFE, 8i J Joffray, 93, 190, 259 Joy, excessive, a cause, 222 Juvenile paresis, 93, 97-106 in sisters, 97, 102 I/" AT ATONIC symptoms, 128, 217 '^ Kidneys, pathology of, 266 Kiernan, 214 Klippel & Servaux, 170 Knapp, 141 Knee-jerk, relative frequency, 125 Kraepelin, 193 Kraftt-Ebing, 22, iSS T ANGDON, 166 j *-^ Lapointe, 238 I Lateral columns, implication of, 89 j Lead poison, 180 " Leather-coated jack," 159 Lemoine, 1S8 I Lewin, 193 Lewis, Bevan, 27, 29, 30, 31, 74, 88, I 122, 127, 133, 135, 137," 164, 251, I 253, 255, 258, 261 Liver, pathology of, 2615 Lloyd,J. H., 153 Locomotor ataxia, 90, 91 Lungs, pathology of, 265 Lunier, 20, 76, 188 MABILLE, 162 Macleod, 165 Macpherson, 64, 146, 151 Magnan, 84, 190 Malaria, paresis mistaken for, 109 Maniacal excitement, 43, 48, 278 Manner of development, 18 Marr, 204 I Marie, 228 I Marinesco, 256 Massage, 271 Masturbation, 114 Medico-legal aspect, 30, 44 ; Medulla, pathology of, 249 Meeson, 170 Melancholic form, 85 I Medical treatment, 273 Mendel, 193, 218 Menses, alteration in, 106 Mental excitement, treatment of, 278 shock, 221 symptoms of general paresis, 41 symptoms of prodromal stage, 27 of first stage, 41 second stage, 55 of third stage, 64 Meynert, 78, 270 Mickle, 24, 77, 114, 125, 146, 165, 193, 205, 211, 213, 215, 216, 221, 224, 248, 249, 251 Middlemass, 106, 109, 203, 225 Mills, 89, 259 Migraine, 146 INDEX. 287 Mode of commencement, 22 Moral perversion, 28, 40, 71, no Morselli, 22 Mortimer, 231 Mott, 191, 259, 263 Muller, 192 Muscular atrophy, 150 incoordination, 65 MACHE, 18S ^^ Nageotte, 259 Nails, 150 Neff, 216 Negro, 209, 210, 212 Nerve cell, pathology of, 255 Nerves, peripheral, pathology of, 260 Neuritis, optic, 33, 140 peripheral, 69 Neuroglia, pathology of, 253 Newcombe, 133 Nightmare, early symptom, 145 Nissl, 263 Norman, 98, 197, 200 OPISTHOTONOS, 129 ^ Optic neuritis, 33, 140 Organic dementia, 175 Osier, 276 pAINS, 32, 61, 72, 145 -*■ Paralysis agitans, iSi Paralytic insanity, 175 Parchappe, 20, 75 Paresis in brothers, 201 in daughter, tabes in mother, 192 in mother and child, 191, 192 ratio to other insanities, 201 ,211 vs. syph. brain dis., 174, 193 Paresis without insanity, 21 Paresthesia, 33 Parsons, 168 Particular symptomatology, no apoplectiform attacks, 129 typical cases of (Campbell Clark), 132 (Tomlinson), 129 bladder, 169 bones, 158 typical cases (Burr, C. B.), 159, 160 (Froelich), i6o classification by Lewis, 127 epileptiform attacks. 133 Particular symptomatology, epilepti- form attacks, typical cases of (Campbell Clark) 135 (Clouston), 134, 135. (Lewis), 134 ( Spitzka), 134 eye symptoms, 137, typical cases (Clouston), 140 (Dawson & Ram- baut), 142 (Finegan), 142 (Knapp), 140 (Savage), 142, 143 (Stearns), 143 (Wiglesworth), 141 facial expression, 116 gait, 120 hallucinations, 114 handwriting, 119 headache, 146 hematoma auris, 161 moral perversion, no typical cases of (Baker, J.), Ill (Berkley), 111, 112 (Simon), 113 (Spitzka), 112 (Stearns), in vertigo, 122 pains, 145 pulse, 168 reflex action and reflexes, 123 crossed reflexes, 126 pupillary reflexes, 125 typical case (Clouston), 124 sensory disturbances, 146 typical cases of (American Journal of In- sanity), 147 (Dawson & Ram- baut), 148 (Spitzka), 147 (Stearns), 147 (Sullivan), 148 sexual instinct, 113 typical cases of (Stearns), "3 sleep, 145 speech, 117 aphasia, 118 typical cases of (Rosen- thal), 118 288 INDEX. Particular symptomatology, speech, typical cases of (Savage), 119 syncopal attacks, 127 typical cases of (Naecke), 128 (Christian), 12S (Stearns), 12S temperature, 164 typical case (Parsons), 167 tremor, 123 trophic changes, 149 typical cases of (Abstract, Arch, de Neu- rol.), 155 (Burr, C. B.), ISS (Fox), 153 (Lloyd, J. H.), 151 unilateral twitching, 136 typical cases of (Lewis), 137 (Turner), 136 urine, 169 Pathogenesis of paresis, 194, 214, 263- 273 Pathology, 246-266 body nutrition, 264 heart, 265 kidneys, 266 liver, 265 lungs, 265 spleen, 266 viscera, 264 macroscopic, of brain, 246 of cerebellum, 249 of cortex, 248 of cranium, 246 of dura, 246 of gray matter, 249 of medulla, 249 of pons, 249 of spinal cord, 250 of white matter, 249 microscopic, of brain, 251-257 of blood-vessels, 252 of nerve-cell. 255 of neuroglia, 253 Perfect, 18 Peripheral nerves, pathology of, 260 Personality, changed, 131 Peterson, 166, 193 " Petrified face," 116 Phelps, 107, 227 Phlegmon, 242 Physical overwork and strain, 220 symptoms of general paresis of prodromal stage, 32 of first stage, 44 of second stage, 56 of third stage, 64 Pick, 69 Pickett, 125 Pierret, 188 Pleurothotonos, 129 Pneumonic hypostasis, 129 Pons, pathology of, 249 Posterior sclerosis, 89, 90 Posture, changes in, 57 Precocious paresis, 93, 97-106 Prodromal stage, 27 mental symptoms, 27 insomnia, 32 moral perversion, 40 physical symptoms, 32 amenorrhea, 33 anesthesia, ^^ depression, 38 digestive disorders, 33 dysmenorrhea, 33 grandiose delusions, 38 irritability, 38, 39 motor troubles, 33, 37, 39 paresthesia, 33 hypothetical case in prodromal stage ( San- key), 24 typical case in (Blandford), (Campbell Clark), 38' 40 (Fisher), 37 (Folsom), 37, 40 ( Hammond), 40 (Savage), 38 (Sinkler),39 (Spitzka),39 Prognosis, 239 supposed recoveries (Savage), 240, 241 (Spitzka), 241 Prophvlactic treatment, 267 Pulse," 168 Pupillary anomalies, 14, 37, 45, 48, 57, Si, 125, 138 DACE and social influences, 209 •'^*- Rambaut, 142, 148 Raymond, 100, 259 INDEX. 289 Rajner, 215, 231 Recovery, supposed, 240, 241 Reflex action and reflexes, 123 iridoplegia, 138 Reflex-excit. excess., case of, 124 Reflexes, abolition of, 65 crossed, 126 superficial, 124 Regis, 21, 188, 201, 211 Reguin, 120 Respiration in sleep, 145 Retention of urine, 169 Rest cure, 271 Remissions, 22S following abscesses, 235 typical cases of (Burr), 235 (Savage), 233 following carbuncles, typical cases of (Stearns), 233 slough (White), 233, 234 typical cases of remission (Blanford), 233 (Bucknill and Tuke), 231, 232 (Mortimer), 231 (Rayner), 231 (Spitzka), 232 (Stearns), 231 (Whitcombe), 230, 232 Ribs, fracture, 15S Robertson, W. Ford, 255, 256, 262 CACRAL decubitus, 65, 72, 150, 2S0 ^ Sankey, 24, 49, 69, 72, 75, 100, 116, 159, 201, 204, 216, 222, 223, 244 Savage, 18, 21, 26, 27, 34, 38, 70, 81, 83, 87, 90, 93, 97, 107, 119, 143, 168, 195, 197, 20I, 206, 213, 220, 222, ?26, 234, 240, 241, 242, 245 - " Scavenger cells," 255 Schules, 241 Sclerosis of spinal cord, 251 Second stage (third period), 55 illustrative case in (Berk- ley), 62 (Clouston), II (Dercum), 59 (Hammond), 62 mental symptoms, 55 physical symptoms, 56 apoplectic attacks, 58 congestive attacks, 58 19 Second stage, physical symptoms, epileptic attacks, 58 impaired articulation, 56 posture, changes of, 57 pupils, changes in, 57 skin, changes in, 57 tremulousness, 58 Sedatives, 275 Salmi, 170 Senile insanity, 179 paresis, 109 , 206 Sensory disturbances, 146 Septic infection, 241 Sex, 201 Sexual ability lost, 114, 135 instinct, 113 Shafer, 256 Shaw, 76, 146 Simon, 113, 240 Sinkler, 39, 238 Skin, changes in, 33, 46, 57 Slave, formerly, develops p., 212 Sleep, 32, 145, 278 Sodomy, 190 Spasm, facial, on protrusion of tongue, 137 Special symptoms, treatment of, 278 Speech, 33,45, 56,65, 117 Spinal cord, pathology of, 250, 258 sclerosis of, 251 general paresis, 88 symptoms in women, 106 Spitzka, 28, 30, 39, 44, 73, 87, 113, 114, 115, 134, 147, 168, 172, 210, 232, 239, 241 Spleen, pathology of, 266 Stages of paresis, 23 (Mickle), 24 (Clouston), 24 Stearns, 32, 66, 86, 91, 95, iii, 112, 113, 122, 128, 144, 148, 213, 231, 233 Sterility, 189 Strabismus, 142 Suicide, 212, 242, 272, 274 Sullivan, W. C, 149 Sunstroke, exciting cause, 215 Suppuration, 240, 241 Symptomatology, no Symptoms, terminal, treatment of, 280 Syncopal attacks, 127 Syncope, 128 Synonyms of paresis, 22 290 INDEX. Syphilis, 193 Syphilitic insanitj, 174 origin, 72, 92, 96, 148, 166 Sjphilization, reciprocal, 107 qpABES dorsalis, 180, 259 •*■ in child of paretic, 191 relation to paresis, 259 Tache cerebrale, 137 Tabetic form, 91 Teeth, 56, 150 Temperament, 200 Temperature, 133, 164 Terminal symptoms, treatment of, 280 Termination, typical cases (Sankey), 243 (Savage), 244 (Christian), 225 (Clouston), 224, 226 (Middlemass), 225 ^Phelps), 227 (Savage), 226 (Worcester), 227 ( Vallon and Marie), 228 Testamentary capacity, 44 Tetanoid seizures, 129 Theories of paresis, 21 Thieving, a symptom, 30 Third stage (fourth period), 64 mental symptoms of, 64 phjsical symptoms of, 64 bed-sores, 65 change in speech, 65 exhaustion, 64 emaciation, 64 muscular incoordination, 65 reflexes, abolition of, 65 typical cases of (Campbell Clark), 72 (Clouston), 66 (Pick), 68 (Stearns), 66 (Sankey). 68, 70 (Savage), 69 Tomlinson, 132, 184, 209 Tonics, 274 Toxemia, chronic, 214, 263, 273 Toxic agents, 214 Traumatism of brain, 214 Travel as a remedy, 271 Treatment, prophylactic, 267 in hereditary predisposi- tion, 267 Treatment, prophylactic in indi- vidual predisposition, 268 in threatened attack, 269 of established disease, 269 food, 272 hydrotherapy, 271, 277 massage, 271 rest cure, 271 travel, 271 medical, 273 antisyphilitic remedies, 275 sedatives, 275 tonics, 274 of special symptoms, 278 Tremor, 33, 45, 46, 56, 58, 65, 122 Trephining, 277 Trophic changes, 65, 149 Tuberculosis, 85, 241 Tuczek, 257, 263 Turner, J., 136 Twins, paresis in, 1S9, 201 UNILATERAL twitching, 136 Ulcerations, 150 Ulcer of foot, perforating, 66, 150 Ulnar nerve, analgesia of, 146 Urine, incontinence, retention of, 169 Urea, 170 yALLON, 162, 22S * Varieties of paresis, 73 classifications of by (Bail- larger), 75 by (Folsom), 73 by (Lewis, B.), 74 by (Meynert), 78 by (Mickle), 77 by (Sankey), 75 by (Spitzka), 73 by ( Voison), 76 by (Shaw), 76 dementia, simple progres- sive, 94 typical case of, (Clouston), 94 (Stearns), 95 (Campbell Clark), 95 (Fisher, E. D.),96 (Savage), 96 double form, 82 typical cases of (Bland- " ford), 82 INDEX. 291 Varieties, double form typical cases of (Campbell Clark), 84 (Magnan), 83 (Savage), 83 galloping form, 80 typical cases of (Jel- liffe), 81 (Savage), 80, 81 juvenile form, 97 typical cases of (Norman), 98 (WiglesMTorth), 99 (Sankey), 100 (Raymond), 101 (Dunn, E. L.), 102 (Hoch, Aug.), 104 (Charcot), 105 (Middlemass), 106 melancholic form, 85 typical cases of (Blan- ford), 87 (Clouston), 86 (Savage), 87 (Spitzka), 87 (Stearns), 86 spinal general, paresis, 88 classification of, B e v an Lewis, 88 typical cases of (Campbell Clark), 91 (Clouston), 90 Varieties, spinal, typical cases or (Down), 91 (Joffroy), 93 (Savage), 89, 90, 92 (Stearns), 91 Vaso-motor disturbances, 33, 45, 85, 137, 271 Vertigo, 33, 122, 127, 132, 140 Viscera, pathology of, 260 Voison, 76, 164 Von Rad, 197 WALLERIAN law, 89, 217 White, 233 Whitcombe, 230, 232' White matter, pathology of, 249 Wiglesworth, 99, 100, 141, 214 Willis, 18, 19 Wilson, G. R., 186, 189, 190 Wolfenden, 170 Woman, paresis in,. 106, 201, 206 typical case of (Savage), 107 (Folsom), 108, 109 (Middlemass, toS Worcester, 228 Workman, 212, 219 VACHER, So " Ziehlen, 239 A Classified Catalogue of Books on Medicine and the Collateral Sciences, Phar- macy, Dentistry, Chemistry, Hygiene, Microscopy, Etc. ^ P. Blakiston's Son & Company, Pub- lishers of Medical and Scientific Books, IOI2 Walnut Street, Philadelphia No. 8. 6-16-02. SUBJECT INDEX Special Catalogues of Books on Pharmacy, Dentistry, Chemistry, Hygiene, and Nursing will be sent free upon application. All inquiries regarding prices, dates of edition, terms, etc., will receive prompt attention. SUBJECT PAGE Alimentary Canal(seeSurgety) 19 Anatomy 3 Anesthetics 14 Autopsies (see Pathology) 16 Bacteriology (see Pathology).. 16 Bandaging (see Surgery) 19 Blood, Examination of 16 Brain 4 Chemistry. Physics 4 Children, Diseases of 6 Climatology 14 Clinical Charts 20 Compends 22, 23 Consumption (see Lungs) 11 Cyclopedia of Medicine 8 Dentistry 7 Diabetes (see Urin. Organs).. 21 Diagnosis 6 Diagrams (see Anatomy) 3 Dictionaries, Cyclopedias 8 Diet and Food 14 Disinfection 11 Dissectors 3 Ear 9 Electricity 9 Embryology 3 Emergencies 19 Eye 9 Fevers 9 Food 14 Formularies , 16 Gynecology 21 Hay Fever 20 Heart 10 Histology 10 Hydrotherapy 14 Hygiene n Hypnotism 14 Insanity 4 Intestines 18 Latin, Medical (see Miscella- neous and Pharmacy) 14, 16 Life Insurance 14 Lungs II Massage 12 Materia Medica 12 SUBJECT. PAGE Mechanotherapy 12 Medical Jurisprudence 13 Mental Therapeutics 4 Microscopy 13 M ilk Analysis (see Chemistry) 4 Miscellaneous 14 Nervous Diseases 14 Nose 20 Nursing 15 Obstetrics ifi Ophthalmology 9 Organotherapy 14 Osteology (see Anatomy) 3 Pathology 16 Pharmacy 16 Physical Diagnosis 6 Physical Training 12 Physiology 17 Pneumotherapy 14 Poisons (see Toxicology) 13 Practice of Medicine 18 Prescription Books ( Pharm'y), 16 Refraction (see Eye) 9 Rest 14 Sanitary Science 11 Skin 19 Spectacles (see Eye) 9 Spine (see Nervous Diseases) 14 Stomach 18 Students' Compends 22, 23 Surgery and Surg'l Diseases, 19 Technological Books 4 Temperature Charts 6 Therapeutics 12 Throat 20 Toxicology 13 Tumors (see Surgery) , 19 U. S. Pharmacopoeia 17 Urinary Organs 20 Urine 20 Venereal Diseases 21 Veterinary Medicine 21 Visiting Lists, Physicians'. (Send for Special Circular ^ Water Analysis 11 Women, Diseases of. 21 Self-Examination for Medical Students. 3500 Questions on Medical Subjects, wiih References to Standard Works in which the correct replies will be found. Together with Questions from State Examining Boards. 3d Edition. Paper Cover, 10 cts. SUBJECT CATALOGUE OF MEDICAL BOOKS. 3 SP^CIAI, 2VOTJS.— The prices given in this catalogue are net, no discount can be allowed retail purchasers under any considera- tion. This rule has been established in order that everyone will be treated alike, a general reduction in former prices having been made to meet previous retail discounts. Upon receipt of the advertised price any book will be forwarded by mail or express, all charges prepaid. ANATOMY. EMBRYOLOGY. MORRIS. Text-Book ot Anatomy. 2d Edition. Revised and Enlarged. 790 Illustrations, 214 ot which are printed in coiors. Thumb Index in Each Copy. Cloth, g6.oo ; Leather, ^7.00 " The ever-growing popularity of the book with teachers and students is an index of its value." — Medical Record, New York. BROOMELL. Anatomy and Histology of the Human Mouth and Teeth. 2d Edition, Enlarged. 330 Illustrations. ^4 50 CAMPBELL. Dissection Outlines. Based on Morris' Anatomy. 2d Edition. .50 DEAVER. Surgical Anatomy. A Treatise on Anatomy in its Application to Medicine and Surgery. With 400 very Handsome full- page Illustrations Engraved from Original Drawings made by special Artists from dissections prepared for the purpose. Three Volumes. Cloth,S2i.oo; Half Morocco or Sheep, $24.00; Half Russia, $27. 00 GORDINIER. Anatomy of the Central Nervous System. With 271 Illustrations, many of which are original. Cloth, $6.00 HEATH. Practical Anatomy. 8th Edition. 300 Illus. ^4.25 HOLDEN. Anatomy. A Manual of Dissections. Revised by A. Hewson, M.D., Demonstrator of Anatomy, Jefferson Medical College. Philadelphia. 320 handsome Illustrations. 7th Edition. In two compact i2mo Volumes. 850 Pages. Large New Type. Just Ready. Vol. I. Scalp^Face — Orbit — Neck — Throat — Thorax — Upper Ex- tremity. gi.50 Vol, II. Abdomen — Perineum — Lower Extremity — Brain — Eye — Ear — Mammary Gland — Scrotum — Testes. 51.50 HOLDEN. Human Osteology. Comprising a Description of the Bones, with Colored Delineations of the Attachments of the Muscles. The General and Microscopical Structure of Bone and its Develop- ment. With Lithographic Plates and numerous lUus. 8th Ed. $5.25 HOLDEN. Landmarks. Medical and Surgical. 4th Ed. .75 HUGHES AND KEITH. Dissections. With a large number ot Colored and other Illustrations. In three Parts : I, Upper and Lower Extremity. fust Ready. ^3.00 II, Abdomen — Thorax. Just Ready. I3.00 III, Head — Xeck — Central Nervous System. Just Ready. ^3.00 MACALISTER. Human Anatomy. Systematic and Topograph- ical. 816 Illustrations. Cloth, $5.00; Leather, $6.00 McMURRICH. Embryology. 270 Illustrations. In Press. MARSHALL. Physiological Diagrams. Eleven Life-Size Colored Diagrams (each seven feet by three feet seven inches). Designed for Demonstration before the Class. In SLeets, Unmounted, $40. 00 ; Backed with Muslin and Mounted on Rollers, ^60.00 ; Ditto, Spring Rollers, in Handsome Walnut Wall Map Case, |ioo.oo; Single Plates — Sheets, ^5.00 ; Mounted, $7.50 Explanatory Key, .50. Purchaser must pay Jr eight charges. MINOT. Embryology. Illustrated. Preparing. POTTER. Compend of Anatomy, Including Visceral Anatomy. 6th Ed. 16 Lith. Plates and 117 other Illus. .80 ; Interleaved, gi.oo WILSON. Anatomy, nth Edition. 429 lUus., 26 Plates. P5.00 SUBJECT CATALOGUE. BRAIN AND INSANITY (see also Nervous Diseases). BLACKBURN. A Manual of Autopsies. Designed for the Use of Hospitals for the Insane and other Public Institutions. Ten full- page Plates and other Illustrations. fi-zs CHASE. General Paresis. Illustrated. Nearly Ready. DERCUM. Mental Therapeutics, Rest, Suggestion. See Cohen, Physio. ogic Ther.ipeutics, p.ige I2. GORDINIER. The Gross and Minute Anatomy of the Central Nervous System. With full-page and other Illustrations. j^6.oo HORSLEY. The Brain and Spinal Cord. The Structure and Functions of. Numerous Illustrations. $2.50 IRELAND. The Mental Affections of Children. 2d Ed. $4.00 LEWIS (BEVAN). Mental Diseases. A Text-Book Having Special Reference to the Pathological Aspects of Insanity. 26 Litho- graphic Plates and other Illustrations. 2d Ed. $7-°o MANN. Manual of Psychological Medicine, ^3-oo PERSHING. Diagnosis of Nervous and Mental Disease. Illustrated #'-25 REGIS. Mental Medicine. Authorized Translation by H. M. Bannister, m.d. ^2.00 SCHOFIELD. The Force of Mind. In Press. SHUTTLEWORTH. Mentally Deficient Children. $1.50 STEARNS. Mental Diseases. With a Digest of L.^ws Relating to Care of Insane. Illustrated. Cloth, J2. 75; Sheep, 1^3.25 TUKE. Dictionary of Psychological Medicine. 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Illustrated. .80; Interleaved, J1.25 WARREN. Dental Prosthesis and Metallurgy. 129 Ills. $1.25 WHITE. The Mouth and Teeth. Illustrated. .40 SUBJECT CATALOGUE. DICTIONARIES AND CYCLOPEDIAS GOULD. The Illustrated Dictionary ot Medicine, Biology and Allied Sciences, Being an Exhaustive Lexicon of Medicine and those Sciences Collateral to it: Biology (Zoology and Botany), Chemistry, Dentistry, Parniacology, Microscopy, etc., with many useful Tables and numerous fine Illustrations. 1633 pages. 5th Ed. Sheep or Half Morocco, Jio.oo ; with Thumb Index, Jn.oo Half Russia, Thumb Index, ^i2.co GOULD. The Medical Student's Dictionary, nth Edition. Illustrated. Including all the Words and Phrases Generally Used inMedicine, with their Proper Pronunciation and Definition, Based on Recent Medical Literature. 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Interleaved, for taking Notes, $1.00. i^~ These Compends are based on the most popular text-books and the lectures of prominent professors, and are kept constantly re- vised, so that they may thoroughly represent the present state of the subjects upon which they treat. JS9' The authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. .^~ They are arranged in the most approved form, thorough and concise, containing nearly looo illustrations and lithograph plates, inserted wherever they could be used to advantage. i^~ Can be used by students of any college. 49~ They contain information nowhere else collected in such a condensed, practical shape. Circular free. No. 1. POTTER. HUMAN ANATOMY. Sixth Revised and Enlarged Edition. Including Visceral Anatomy. Can be used with either Morris's or Gray's Anatomy. 117 Illustrations and 16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. By Samuel O. L. Potter, m.d.. Professor of the Practice of Medicine, College of Physicians and Surgeons, San Francisco ; Brigade Surgeon, U. S. Vol. No. 2. HUGHES. PRACTICE OF MEDICINE. Part I. Sixth Edition, Enlarged and Improved. By Daniel E. Hughes, m.d., Physician-in-Chief, Philadelphia Hospital, late Demonstrator of Clinical Medicine, Jefferson Medical College, Phila. No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. Sixth Edition, Revised and Improved. Same author as No. 2. No. 4. BRUBAKER. PHYSIOLOGY. Tenth Edition, with Illustrations and a table of Physiological Constants. Enlarged and Revised. By A. P. Bkubaker, m.d., Professor of Physiology and General Pathology in the Pennsylvania College of Dental Surgery ; Adjunct Professor of Physiology, Jefferson Medical College, Philadelphia, etc. No. 5. LANDIS. OBSTETRICS. Seventh Edition. By Henry G. Landis, m.d. Revised and Edited by Wm. H. Wells, m.d.. Demonstrator of Clinical Obstetrics, Jefferson Medical College, Philadelphia. Enlarged. 52 Illustrations. No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth Revised Edition (U. S. P. 1890). By Samuel O. L. Potter, m.d.. Professor of Practice, College of Physicians and Surgeons, San Francisco; Brigade Surgeon, U. S. Vol. MEDICAL BOOKS. ?QUIZ-COMPENDS ?— Continued. No. 7, WELLS. GYNECOLOGY. Second Edition. ByWM. H. Wells, m.d., Demonstrator of Clinical Obstetrics, JeflFersoD Medical College, Philadelphia. 140 Illustrations. No. 8. GOULD AND PYLE. DISEASES OF THE EYE AND REFRACTION. Second Edition. Including Treatment and Surgery, and a Section on Local Therapeutics. By George M. Gould, m.d., and W. L. Pyle, m.d. With Formula, Glossary Tables, and 109 Illustrations, several of which are Colored. No. g. HORW^ITZ. SURGERY, Minor Surgery, and Bandag- ing. Fifth Edition, Enlarged and Improved. By Grvillb HoRwiTZ, E. s., M.D., Clinical Professor of Genito-Urinary Surgery and Venereal Diseases in JeflFerson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth Edition. Including Urinalysis, Animal Chemistry, Chemistry ol Milk, Blood, Tissues, the Secretions, etc. By Henry Leffmann, M.D., Professor of Chemistry in the Woman's Medical College of Penna ; Pathological Chemist, Jefferson Medical College Hospital. No. II. STEWART. PHARMACY. Fifth Edition. Based upon Prof. Remington's Text-Book of Pharmacy. By F. E. Stewart, M.D., PH.G., late Quiz-Master in Pharmacy and Chemistry, Phila- delphia College o£ Pharmacy ; Lecturer at Jefferson Medical College. Carefully revised in accordance with the new U. S. P. No. 12. BALLOU. VETERINARY ANATOMY AND PHY- SIOLOGY. Illustrated. By Wm. R. Ballou, m.d.. Professor of Equine Anatomy at New York College of Veterinary Surgeons ; Physician to Bellevue Dispensary, etc. 29 graphic Illustrations No. 13. \VARREN. DENTAL PATHOLOGY AND DEN- TAL MEDICINE. Third Edition, Illustrated. Containing a Section on Emergencies. By Geo. W. Warren, d.d.s., Chiet of Clinical Staff, Pennsylvania College of Dental Surgery. No. 14. HATFIELD. DISEASES OF CHILDREN. Second Edition. Colored Plate. By Marcus P. Hatfield, Profes- sor of Diseases of Children, Chicago Medical College. No. 15. THAYER. GENERAL PATHOLOGY. By A. E. Thayer, m.d., Cornell University Medical College. Illustrated. No. 16. SCHAMBERG. DISEASES OF THE SKIN. Second Edition. By Jay F. Schameerg, m.d.. Professor of Diseases of the Skin, Phib-delphia Polyclinic. Second Edition, Revised and Enlarged. 105 handsome Illustrations. No. 17. GUSHING. HISTOLOGY. By H. H. Gushing, m.d.. Demonstrator of Histology, Jefferson Medical College, Philadel- phia. Illustrated. No. 18. THAYER. SPECIAL PATHOLOGY. Illustrated. By same Author as No. 15. Price, each, Cloth, .80. Interleaved, for taking Notes, $1.00. Careful attention has been given to the construction of each sentence, and while the books will be found to contain an immense amount of knowledge in small space, they will likewise be found, easy reading ; there is no stilted repetition of words ; the style is clear, lucid, and dis- tinct. The arrangement of subjects is systematic and thorough ; there Is a reason for every word. They contain over 600 illustrations THE STANDARD TEXT-BOOK MORRIS' Anatomy SECOND EDITION Rewritten. Revised. Improved WITH MANY NEW ILLUSTRATIONS Has been recommended as a text-book at more than seventy of the most prominent medical schools in the United States and Canada, and is considered by all anatomists as a standaid authority. It contains many features of special advantage to students. A complete Text-book. Edited by Henry Morris, f.r.c.s., Surgeon to, and Lecturer on Anatomy at, Middlesex Hospital, assisted by J. Bland Sutton, f.r.c.s., J. H. Davies-Colley, f.r.c.s., Wm. J. Walsham, f.r.c.s., H. St. John Brooks, m.d., R. Mar- cus GuNN, f.r.c.s., Arthur Hensm.\n, f.r.c.s., Fred- erick Treves, f.r.c.s., William Anderson, f.r.c.s., Prof. W. H. A. Jacobson, and Arthur Robinson, m.r.c.s. Octavo. With 790 Illustrations, of which a large number are printed in colors CLOTH, $6.00; LEATHER, $7.00 " The ever-growing popularity of the book with teach- ers and students is an index of its value, and it may safely be recommended to all interested." — From The Medical Record, New York. "Of all the text-books of moderate size on human anatomy in the English language, Morris is undoubtedly the most up-to date and accurate." — From The Philadel- phia Medical Journal. THUMB INDEX IN EACH COPY COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RC 418 C38 1902 C.1 General.pares: 2002147491 clinical rr ^ n 1Q88